Coronavirus updates November 2022

[missy]

"

Long COVID Patients Find Aid and Risk in Online Support Groups​

Jill Sylte wrote that she would not have made it through long COVID without her Facebook support group, Survivor Corps.

"It has helped me so much, by being able to be in touch with other long hauler members," the Pensacola, FL, woman wrote in a comment on a group post in March. "Everyone in this group understands each other. Unless you are a long-hauler you don't completely feel what we are going through."

The listing of hundreds of Facebook long COVID communities goes on for page after page. Some have a few members. Survivor Corps has nearly 200,000.


"This space has absolutely exploded in the past 2 years," says Fiona Lowenstein, a journalist who started the group called Body Politic that has become a COVID support group.





The public Facebook COVID and long COVID groups are studded with posts and comments like this among the hundreds that can come in a day.

On a single day in late October, Survivor Corps posters were trying to find out if anyone else had hair loss, rashes, sleep apnea issues, migraines, bladder problems, neck pain, vertigo, allergies, or double vision. An October post on increasing cholesterol levels drew more than 50 comments within 17 hours.

The support groups provide advice and encouragement that patients often are not getting from their medical providers, friends, and family. They're also a source of valuable data for researchers. But some doctors worry that they are not always entirely benign, even as they gain popularity.

From Hospital Meeting Rooms to Online​

Patient support groups have moved out of the hospital community room and onto Facebook, Reddit, WhatsApp, and other online spaces. Before long COVID was recognized, these forums were a lifeline for patients with chronic conditions.

After having lived with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) for years, long COVID seemed familiar to JD Davids, a chronic disabilities activist in Brooklyn who works with a group called Long COVID Justice. He thinks patient groups are important for otherwise healthy people with unexplained post-infection symptoms like extreme fatigue.

"One of the problems is that these often-volunteer-based patient support groups are all that people have," Davids says. The groups are essential to patients but need to be part of a comprehensive care plan, he says.


While offering support, online groups can be sources of misinformation and unproven remedies. Advocates and doctors say some group members come to them asking about miracle cures and supplements.


Alexander Truong, MD, a doctor at Emory University in Atlanta who works with long COVID patients, says many of his patients have bought expensive but useless vitamins and supplements they learn about online.

"A lot of these patients are grasping at straws to try to figure out anything that can make them feel better and they are very vulnerable to this kind of scam," he said during a live online forum hosted by SciLine, a project of the American Association for the Advancement of Science.

Privacy can be another issue. Tens of thousands of people post details about their health and lives in public Facebook groups. Anyone signed on to Facebook can read the posts.

A Treasure Trove of Data​

Analysis of these private patient conversations can also produce useful data for researchers. The organization Patients Like Me, founded in 2005 to support families with ALS (amyotrophic lateral sclerosis, or Lou Gehrig's disease) is built around the concept.

Researchers at Yale and elsewhere are already working with long COVID patient groups. Facebook's Data for Good program offers three COVID databases based on posting on the platform. The Patient-Led Research Collaborative provided data for a study published in The Lancet that was among the first the characterize long COVID.

For Facebook groups, the site's rules requiregroup moderators to "obtain user consent for your use of the content and information that you collect." But the platform has been fighting "unauthorized scrapers" who lift data off Facebook and republish it.




The Survivor Corps group, the largest long COVID Facebook group with nearly 200,000 members, is public. Anyone can read any of the posts. Those signed into Facebook can click on the "People" tab and see any group members who have a single mutual contact.

Diana Berrent, a New York photographer who caught COVID-19 early in the pandemic, is the founder of and a contributor to the Survivor Corps Facebook group and its sister website. She thinks the choice of support group might be a matter of where someone already spends their time online.

"And I don't see it's a privacy issue," she says. "It's really whatever platform you're most comfortable in."

Berrent also runs polls and had worked with researchers at Yale, the National Institutes of Health, and elsewhere.Although the data on her site can be valuable, Berrent says she has turned down offers from buyers.

At the same time, she says she received grant money from the Bill & Melinda Gates Foundation and the Chan Zuckerberg Initiative when she started her work, but it has run out. She doesn't want to ask for donations from support group members. She says she has funds to pay for one full-time employee and one part-time employee.

Group moderators say money for this cause is hard to come by. And this need for funding can be a vulnerability. Some well-established patient groupsspecializing in a range of conditions get money from the pharmaceutical industry. But with no marketable treatment for long COVID, corporate sponsors are scarce.

That can lead to please for cash."To be blunt, our financial situation is dire. We estimate Body Politic, including our Slack space, will cease to exist by early 2023 without funding (GOAL: $500k)," Body Politic said in an Instagram postearly in November.

"Our team is pursuing private donors, foundations, and strategic partners, and we could use more connections and insights on potential partners."

Groups like Body Politic say they need money to hire more moderators, pay for increasingly robust software subscriptions, advocate for patients, offer public education, and work with government and health leaders.

The Struggle to Keep Up​

Hosting a group can be a big commitment. Florida nurse Laney Bond says when COVID-19 emerged, she set up a Facebook group to help fellow nurses. Bond, who had been treated previously for mast cell activation syndrome -- which can cause allergic reactions – started to develop long COVID symptoms like heart problems and brain fog.


Bond says she noticed online discussions about long COVID patients with similar symptoms and wanted to share the evidence-based medicine she had been gathering about post-viral illness.


"I just threw a group out there for people in hopes that the information and my experience would shorten their journey," she says.


Now Bond has trouble keeping up with the 95,000 members signed up for her COVID-19 Long Haulers Support group. She also hosts a web page where she posts simplified information on COVID-19 she gets from the National Institutes of Health.


Bond is a volunteer with a day job. She says she makes about $10 a month from Google ads on the website she runs in addition to the Facebook page, but otherwise, has no funding source. So she's backed up on the moderation.


"It's too much, but I do my best," she says. Facebook has provided some moderator tools to help.

A New Age of Advocacy​

The internet has spawned the engaged patient – people who do their own research and plan care along with their doctors. The engaged long COVID patient is bringing in "a new age of advocacy," David Putrino, PhD, a physical therapist and professor at the Icahn School of Medicine at Mount Sinai in New York City, writes in a Perspective for Medscape, WebMD's sister site for medical professionals.


"Such organizations are driving incredibly comprehensive biomedical and clinical research, and doing so at an unprecedented pace," he writes.


Support from other patients is essential for people with chronic conditions, but it need to be paired with solid medical care and support services, advocates say.


Davids says he is most active in the Body Politic channel on the online tool Slack, where 11,000 members meet privately. He appreciates that a human, not an algorithm, chooses which posts he sees. And he thinks Body Politic is well moderated, something he and others suggest patients consider when joining a group.


"Support groups should be moderated. You could ask as a support group member -- how are our moderators trained? How do you know are they equipped to manage the space?" he asks.


The Survivor Corps page is "heavily, heavily, moderated," Berrent says. Users "cannot state a scientific fact unless they link to a legitimate source," she says. They can talk about what has helped them, but they can't give medical advice or talk politics.


Conflict among group members may be a source of agitation and that could be a drawback, Davids cautions. He suggests that patients try out a few groups and see what happens when conflicts emerge.


"How is it handled? Does it sit right with you? Does it get your heart racing -- which you certainly don't need?" he says. Davids offers a list of recommended groups on his Long COVIDJustice page.


The Body Politic group was founded as a wellness collective before the pandemic but morphed into a long COVID group in 2020 when Lowenstein and another member got sick. They say they couldn't find help anywhere else.


Lowenstein, who now has mild symptoms and no longer runs the group, agrees that patient support groups should be well-moderated. Lowenstein also thinks they should be limited to those with long COVID and worries that journalists and people curious about COVID dwell on the public sites.


"It's not a particularly private or safe-feeling space for people with long COVID," Lowenstein says.


Facebook has taken some action on COVID communities, including an effort to look for members in distress. Bond, who runs the COVID Care Group, says she was vetted by Facebook earlier this year and they shared some moderator tools, including a red flag for postings that suggest suicide. Bond says she did 20 suicide interventions last year for long COVID patients.


Meta, the parent company of Facebook and Instagram, has COVID and vaccine misinformation policies. The company reports that it has removed 27 million pieces of content from Facebook and Instagram feeds and more than 3,000 accounts, pages, and groups for violations.


But the stream of posts and comments continues. Christian Sandrock, MD, director of critical care at University of California Davis, says many of his long COVID patients get information on Facebook.


"What we really say is — almost as an absolute — is if anyone is saying this definitely works, this is awesome, it is a quick fix … don't go with," he said during the SciLine briefing. "We know this disease is complex. We know we don't have good answers."

Sources​

Jill Sylte, Pensacola, FL.


Cassi Joseph Wisener.


Fiona Lowenstein, founder, Body Politic.


JD Davids, chronic disabilities activist, Brooklyn.


Laney Bond, nurse, founder of COVID-19 Long Haulers Support group.


SciLine: "Long COVID update."

"

 

[Gloria27]

Folks, no conspiracy theories are allowed here and we’re tired of editing posts, so we’re removing them entirely if they break the rules. Post things from official or peer reviewed sources. YouTube videos from random people on either side this “debate” will be removed, and time outs given. Everyone has been warned already, this is the last warning.

Please act like adults and respect the policies if you’d like to continue this conversation.

Ella, where are these conspiracy theories?

The video was posted by the UK Parliament Official Channel and the first one was just a cut from that video.

That is very important because the vaccine efficacy was questioned in the EU Parliament too and resulted in Pfizer admitting the vaccine wasn't tested on preventing transmission.

Parliamentary question | Implications of statement by Pfizer executive for COVID passport | P-003358/2022 | European Parliament

Priority question for written answer P-003358/2022 to the Commission Rule 138 Bernhard Zimniok (ID)

www.europarl.europa.eu

Missy's post above doesn't follow the rules, she just quoted stuff from questionable sources, some nurses and activists, not official sources nor peer reviewed studies.

 

[missy]

"

Masks lead to fewer covid cases in schools

The latest​ Public schools that continued to require students to wear masks reported fewer coronavirus infections, my colleague Donna St. George reports. The study was based on schools in the Boston area and found ending mask requirements was “associated with an additional 45 coronavirus cases per 1,000 students and staff members,” St. George writes. The research, published in the New England Journal of Medicine, adds to well-documented evidence supporting mask-wearing to prevent the spread of the coronavirus. The Centers for Disease Control and Prevention recommends people ages 2 and older wear masks indoors and in public spaces when they are in settings where infection rates are high. Reinfections with the coronavirus can still prove dangerous in unvaccinated, vaccinated and boosted people, Ariana Eunjung Cha of The Washington Post reports. Researchers analyzed the medical records of 5.8 million patients at the Department of Veterans Affairs. They found that nearly 41,000 people with reinfections “tended to have more complications in various organ systems both during their initial illness and longer term, and they were more likely to be diagnosed with long covid than people who did not get another infection,” Cha writes. A growing body of research shows an increased risk of covid-related complications with every reinfection. Health experts worry that repeat infections can worsen long covid symptoms. Other important news​ Infants younger than 6 months, who are not eligible for the coronavirus vaccine, have high covid-related hospitalization rates compared with other children. Covid patients treated with the antiviral Paxlovid were less likely to suffer from long covid symptoms, my colleague Frances Stead Sellers reports.

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[missy]

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No Benefit of Rivaroxaban in COVID Outpatients: PREVENT-HD​

Sue Hughes
November 10, 2022

A new US randomized trial has failed to show benefit of a 35-day course of oral anticoagulation with rivaroxaban for the prevention of thrombotic events in outpatients with symptomatic COVID-19.
The PREVENT-HD trial was presented at the American Heart Association (AHA) Scientific Sessions 2022 by Gregory Piazza, MD, Brigham and Women's Hospital, Boston, Massachusetts.
"With the caveat that the trial was underpowered to provide a definitive conclusion, these data do not support routine antithrombotic prophylaxis in nonhospitalized patients with symptomatic COVID-19," Piazza concluded.
PREVENT-HD is the largest randomized study to look at anticoagulation in nonhospitalized COVID-19 patients and joins a long list of smaller trials that have also shown no benefit with this approach.

However, anticoagulation is recommended in patients who are hospitalized with COVID-19.




Piazza noted that the issue of anticoagulation in COVID-19 has focused mainly on hospitalized patients, but most COVID-19 cases are treated as outpatients, who are also suspected to be at risk for venous and arterial thrombotic events, especially if they have additional risk factors. Histopathological evidence also suggests that at least part of the deterioration in lung function leading to hospitalization may be due to in situ pulmonary artery thrombosis.
The PREVENT-HD trial explored the question of whether early initiation of thromboprophylaxis dosing of rivaroxaban in higher risk outpatients with COVID-19 may lower the incidence of venous and arterial thrombotic events, reduce in situ pulmonary thrombosis and reduce the worsening of pulmonary function that may lead to hospitalization, and reduce all-cause mortality.
The trial included 1284 outpatients with a positive test for COVID-19 and who were within 14 days of symptom onset. They also had to have at least one of the following additional risk factors: age over 60 years; prior history of venous thromboembolism (VTE), thrombophilia, coronary artery disease, peripheral artery disease, cardiovascular disease or ischemic stroke, cancer, diabetes, heart failure, obesity (body mass index ≥ 35 kg/m2) or D-dimer > upper limit of normal. Around 35% of the study population had two or more of these risk factors.

Patients were randomized to rivaroxaban 10 mg daily for 35 days or placebo.
The primary efficacy endpoint was time to first occurrence of a composite of symptomatic VTE, myocardial infarction (MI), ischemic stroke, acute limb ischemia, noncentral nervous system (non-CNS) systemic embolization, all-cause hospitalization, and all-cause mortality up to day 35.

The primary safety endpoint was time to first occurrence of International Society on Thrombosis and Hemostasis (ISTH) critical site and fatal bleeding.

A modified intension-to-treat analysis (all participants taking at least one dose of study intervention) was also planned.


The trial was stopped early in April this year because of a lower than expected event incidence (3.2%) compared with the planned rate (8.5%), giving a very low likelihood of being able to achieve the required number of events.


Piazza said reasons contributing to the low event rate included a falling COVID-19 death and hospitalization rate nationwide, and increased use of effective vaccines.


Results of the main intention-to-treat analysis (in 1284 patients) showed no significant difference in the primary efficacy composite endpoint, which occurred in 3.4% of the rivaroxaban group versus 3.0% of the placebo group.




In the modified intention-to-treat analysis (which included 1197 patients who actually took at least one dose of the study medication) there was shift in the directionality of the point estimate (rivaroxaban 2.0% vs placebo 2.7%), which Piazza said was related to a higher number of patients hospitalized before receiving study drug in the rivaroxaban group. However, the difference was still nonsignificant.


The first major secondary outcome of symptomatic VTE, arterial thrombotic events, and all-cause mortality occurred in 0.3% of rivaroxaban patients versus 1.1% of placebo patients, but this difference did not reach statistical significance.


However, a post-hoc exploratory analysis did show a significant reduction in the outcome of symptomatic VTE and arterial thrombotic events.


In terms of safety, there were no fatal critical site bleeding events, and there was no difference in ISTH major bleeding, which occurred in one patient in the rivaroxaban group versus no patients in the placebo group.


There was, however, a significant increase in nonmajor clinically relevant bleeding with rivaroxaban, which occurred in nine patients (1.5%) versus one patient (0.2%) in the placebo group.


Trivial bleeding was also increased in the rivaroxaban group, occurring in 17 patients (2.8%) versus five patients (0.8%) in the placebo group.


Discussant for the study, Renato Lopes, MD, Duke University Medical Center, Durham, North Carolina, noted that the relationship between COVID-19 and thrombosis has been an important issue since the beginning of the pandemic, with many proposed mechanisms to explain the COVID-19–associated coagulopathy, which is a major cause of death and disability.


While observational data at the beginning of the pandemic suggested patients with COVID-19 might benefit from anticoagulation, looking at all the different randomized trials that have tested anticoagulation in COVID-19 outpatients, there is no treatment effect on the various different primary outcomes in those studies and also no effect on all-cause mortality, Lopes said.


He pointed out that PREVENT-HD was stopped prematurely with only about one third of the planned number of patients enrolled, "just like every other outpatient COVID-19 trial."


He also drew attention to the low rates of vaccination in the trial population, which does not reflect the current vaccination rates in the United States, and said the different direction of the results between the main intention-to-treat and modified intention-to-treat analyses deserve further investigation.


However, Lopes concluded, "The results of this trial, in line with the body of evidence in this field, do not support the routine use of any antithrombotic therapy for outpatients with COVID-19."


The PREVENT-HD trial was sponsored by Janssen. Piazza has reported receiving research support from Bristol-Myers Squibb/Pfizer Alliance, Bayer, Janssen, Alexion, Amgen, and Boston Scientific, and consulting fees from Bristol-Myers Squibb/Pfizer Alliance, Boston Scientific, Janssen, NAMSA, Prairie Education and Research Cooperative, Boston Clinical Research Institute, and Amgen.


American Heart Association (AHA) 2022 Scientific Sessions: Presentation number 19481.

"

 

[missy]

"

COVID Reinfection More Lethal​

by Kristen Monaco, Staff Writer, MedPage Today November 11, 2022

Compared with the first bout, the second time around with COVID infection is riskier in terms of death, hospitalization, and developing long COVID. (Nature Medicine)
No, Eli Lilly did not announce on Twitter that "insulin is free now." (Forbes)
Pregnant detained migrants under the age of 18 will have access to abortions, the Biden administration said. (AP)
Vape maker Juul plans to lay off 30% of its staff but apparently secured financing to stave off bankruptcy. (Wall Street Journal)

Without government-paid vaccines, treatments, and tests, could we be gearing up for a tough COVID winter? (STAT)
Supreme Court Justice Sonia Sotomayor rejected an emergency challenge to New York City's COVID-19 vaccine mandate for public workers. (The Hill)
Respiratory syncytial virus (RSV) is responsible for one in 56 hospitalizations of healthy young kids in high-income European countries. (Lancet Respiratory Medicine)
Meanwhile, a Kansas City school had to temporarily close after dozens of students and staff fell ill with RSV, the flu, or COVID. (ABC News)
Over 100 healthcare organizations already penned their names to a government-initiated climate pledge agreeing to meet bold targets for emissions reduction and climate resilience, an HHS delegation to the United Nations Climate Conference announced.
Former first lady Michelle Obama is opening up about menopause and her experience with hormone therapy. (NBC News)
California is suing several companies, including DuPont and 3M, over costs to clean up pollution from polyfluoroalkyl and perfluoroalkyl substances (PFAS), the so-called forever chemicals. (Reuters)

Following in Oregon's footsteps, Colorado became the second state to legalize the use of magic mushrooms in "healing centers" following a very close vote earlier this week. (The Colorado Sun)
This year, more than 3 million middle and high school students, representing one in every nine, said they used a tobacco product in the past month, according to new CDC data.
The FDA approved tremelimumab (Imjudo) in combination with durvalumab (Imfinzi) and platinum-based chemotherapy for adults with metastatic non-small cell lung cancer.
And brentuximab vedotin (Adcetris) gained a new indication for kids ages 2 years and up with previously untreated high risk classical Hodgkin lymphoma in combination with chemotherapy, Seagen announced.
In a small study of untreatable cancer, a CRISPR-powered CAR T-cell therapy proved safe and able to stabilize disease progression in a handful of patients. (Nature)
Lebanon is facings a cholera outbreak for the first time in almost 30 years, and the oral vaccine is in short supply. (NPR)

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[missy]

"

Should I worry about RSV?​

I've heard about the high rate of respiratory syncytial virus (RSV) this year, which is especially risky for infants and older people. How concerning is this and is there a way to protect the vulnerable people in our lives? Kelly, Los Angeles Cases of RSV are indeed on the rise. But there are actually three viruses circulating at high levels right now: RSV, Covid and influenza. Just this month, the US Centers for Disease Control and Prevention issued an alert to health-care providers, warning that these three viruses together are causing unseasonably high rates of respiratory disease — especially among young children. The flu normally doesn’t peak until later in the winter. “Currently, outpatient medical visits for respiratory illnesses are occurring at a frequency above the national baseline,” says Katrine Wallace, an epidemiologist at the University of Illinois at Chicago. “Visits continue to rise week over week with a steep trajectory, and the greatest percentage of people seeking medical attention for respiratory illness is children 0-4 years.” Respiratory viruses are overwhelming children’s hospitals. Photographer: E+/Getty Images Every state is seeing some evidence of this trend, but it is more pronounced in the southern and southeastern US. Wallace says there are two factors contributing to this troubling trend. The first is that we’re all leaving the house more and wearing masks less often. Our Covid-era habits had kept seasonal viruses at bay. Adding to that, young children born during the pandemic or just before it have had less exposure to these viruses and therefore less opportunity to develop immunity. The result is what some have dubbed a “tripledemic.” “This sharp increase in cases is causing emergency rooms and pediatric intensive care units to be at capacity,” she says. So what can we all do to slow circulation — and make sure we all get to enjoy our holiday pies virus-free? Wallace provided me with a handy list: Get vaccinated against Covid and the flu. If you get your shots now, Wallace adds, you will be all boosted up by Thanksgiving. Don’t take part in gatherings if you have cold or flu symptoms, no matter how mild they are. “If in doubt, don’t attend,” Wallace says. Take a rapid test for Covid just before getting together with groups of people. Practice multiple prevention measures. No one tactic is 100%, but things like masking, gathering outside (weather permitting), opening windows and washing your hands can all help to reduce the spread of viruses. “Moving into the holidays, it is very important to take precautions to protect yourself and vulnerable family and community members against respiratory viruses,” says Wallace, “and to celebrate safely in groups.” — Kristen V. Brown "

 

[missy]

"

Will New Guidelines on Antibiotic Stewardship Help in Future Pandemics?​

Authors: News Author: Marta Zaraska; CME Author: Charles P. Vega, MDFaculty and Disclosures
CME / ABIM MOC / CE Released: 11/11/2022


Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.

Clinical Context​

Antimicrobial stewardship has not always been top-of-mind during the COVID-19 pandemic, and the authors of the current study described the different forces affecting antimicrobial prescribing from 2020 to the present time. Early reports from China at the outset of the pandemic conveyed that up to half of all deaths related to COVID-19 were due to secondary infection; however, subsequent studies found rates of co-infection of SARS-CoV-2, the virus that causes COVID-19, with other organisms in 3.5% of hospitalized patients, and 14.3% of these patients developed secondary infections.

Of course, the high risk for hospitalization and mortality and lack of clear guidelines or treatment alternatives for the management of COVID-19 also contributed to antimicrobial overuse, but the authors of the current review noted that this phenomenon was most prevalent early in the pandemic and faded with time. The effect of COVID-19 on antimicrobial resistance patterns is largely unknown.

The current study by Khan and colleagues provides a review of research into the use of antimicrobial drugs during the COVID-19 pandemic.

Study Synopsis and Perspective​

A statement by the Society for Healthcare Epidemiology of America (SHEA), published online on September 14 in Infection Control & Hospital Epidemiology,[1] offers healthcare providers guidelines on how to prevent inappropriate antibiotic use in future pandemics and avoid some of the negative scenarios that have been seen with COVID-19.

According to the US Centers of Disease Control and Prevention (CDC),[2] the COVID-19 pandemic brought an alarming increase in antimicrobial resistance in hospitals, with infections and deaths caused by resistant bacteria and fungi going up by 15%. For some pathogens, such as the Carbapenem-resistant Acinetobacter, that number is now as high as 78%.

The culprit might be the widespread antibiotic overprescription during the current pandemic. A 2022 meta-analysis[3] revealed that in high-income countries, 58% of patients with COVID-19 were given antibiotics, whereas in lower- and middle-income countries, 89% of patients were put on such drugs. Some hospitals in Europe[4] and the United States[5] reported similarly elevated numbers, sometimes approaching 100%.

"We've lost control," Natasha Pettit, PharmD, pharmacy director at University of Chicago Medicine, told Medscape Medical News. Pettit was not involved in the SHEA study.

"Even if CDC didn't come out with that data I can tell you right now, more of my time is spent trying to figure out how to manage these multi-drug-resistant infections, and we are running out of options for these patients," added Pettit.

"Dealing with uncertainty, exhaustion, critical illness in often young, otherwise healthy patients, meant doctors wanted to do something for their patients," said Tamar Barlam, MD, an infectious diseases expert at the Boston Medical Center who led the development of the SHEA white paper, in an interview with Medscape Medical News.

That something often was a prescription for antibiotics, even without a clear indication that they were actually needed. A British study[6] revealed that in times of pandemic uncertainty, physicians often reached for antibiotics "just in case" and referred to conservative prescribing as "bravery."

Studies have shown, however, that bacterial co-infections in COVID-19 are rare. A 2020 meta-analysis[7] of 24 studies concluded that only 3.5% of patients had a bacterial co-infection on presentation, and 14.3% had a secondary infection. Similar patterns had previously been observed in other viral outbreaks. Research on MERS-CoV,[8] for example, documented only 1% of patients with a bacterial co-infection on admission. During the 2009 H1N1 influenza pandemic, that number was 12% of non-intensive care unit (ICU) hospitalized patients.

Yet, according to Pettit, even when such data became available, it did not necessarily change prescribing patterns.

"Information was coming at us so quickly, I think the providers didn't have a moment to see the data, to understand what it meant for their prescribing. Having external guidance earlier on would have been hugely helpful," she told Medscape Medical News.

That is where the newly published SHEA statement comes in: It outlines recommendations on when to prescribe antibiotics during a respiratory viral pandemic, what tests to order, and when to deescalate or discontinue the treatment. These recommendations include, for instance, advice to not trust inflammatory markers as reliable indicators of bacterial or fungal infection and to not use procalcitonin routinely to aid in the decision to initiate antibiotics.

According to Barlam, one of the crucial lessons here is that if physicians see patients with symptoms that are consistent with the current pandemic, they should trust their own impressions and avoid reaching for antimicrobials "just in case."

Another important lesson is that antibiotic stewardship programs have a huge role to play during pandemics. They should monitor prescribing and also compile new information on bacterial co-infections as it gets released and make sure it reaches the physicians in a clear form.

Evidence suggests that such programs and guidelines do work to limit unnecessary antibiotic use. In one medical center in Chicago, for example, before recommendations on when to initiate and discontinue antimicrobials were released, over 74% of patients with COVID-19 received antibiotics. After guidelines were put in place, the use of such drugs fell to 42%.

Pettit believes, however, that it is important not to leave each medical center to its own devices.

"Hindsight is always twenty-twenty," she said, "but I think It would be great that if we start hearing about a pathogen that might lead to another pandemic, we should have a mechanism in place to call together an expert body to get guidance for how antimicrobial stewardship programs should get involved."

One of the authors of the SHEA statement, Susan Seo, reports an investigator-initiated Merck & Co., Inc. grant on cost-effectiveness of letermovir in patients with hematopoietic stem cell transplant. Another author, Graeme Forrest, reports a clinical study grant from Regeneron Pharmaceuticals, Inc. for inpatient monoclonals against SARS-CoV-2. All other authors report no conflicts of interest. The study was independently supported.

Study Highlights​

• Researchers searched for studies that included ≥ 50 patients with laboratory-confirmed COVID-19. All studies had to include a focus on antimicrobial use.
• The main study outcome was the trend in antimicrobial use during the pandemic. The research team performed a subanalysis to compare this outcome in high- and middle-/low-income countries.
• The initial search yielded 1671 articles, and 43 underwent complete analysis. 33 studies were completed in high-income countries, and 34 studies focused on hospital or other secondary-care services.
• 35 studies were judged to be of satisfactory or good quality.
• 2 studies that compared the use of antimicrobial drugs in the United States in early 2020 vs previous years found conflicting results. In one study, there was little change in the use of antimicrobials during the pandemic. In the other study, antimicrobial prescriptions actually declined.
• In contrast, several studies from Europe demonstrated that antimicrobial use increased in 2020 vs previous years: 23% of antimicrobial prescriptions were judged to be inappropriate in one study.
• In a study from Pakistan, 88% of antimicrobial prescriptions were not preceded by any testing for pathogens. Unsurprisingly, the pandemic was associated with higher rates of antimicrobial prescribing there.
• 27 studies provided data for a meta-analysis of the overall rate of antimicrobial use during infection with SARS-CoV-2, the virus that causes COVID-19; 68% of patients with COVID-19 were prescribed antimicrobial drugs.
• There was a profound difference in overall antimicrobial use in comparing high-income countries (58%) and middle-/low-income countries (89%).
• The most commonly prescribed antimicrobials among patients with COVID-19 included ceftriaxone, azithromycin, and piperacillin-tazobactam. Azithromycin use was particularly common at the outset of the pandemic.

Figure. Use of Antimicrobial Agents During Infection With COVID-19

Clinical Implications​

• Early reports from China at the outset of the pandemic described that up to half of all deaths related to COVID-19 were due to secondary infection; however, subsequent studies found rates of bacterial co-infection of COVID-19 in 3.5% of hospitalized patients, and 14.3% of these patients developed secondary infections.
• The current meta-analysis by Khan and colleagues found that 68% of patients with COVID-19 received antimicrobial drugs. This difference was particularly marked in middle-/low-income countries. The most commonly prescribed antimicrobials among patients with COVID-19 included ceftriaxone, azithromycin, and piperacillin-tazobactam.

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[missy]

"

China Shortens Quarantines as It Eases Some of Its COVID Rules​

By Ryan Woo and Tony Munroe
November 11, 2022

BEIJING (Reuters) - China on Friday eased some of its strict COVID rules, including shortening quarantines by two days for close contacts of infected people and for inbound travellers, and removing a penalty for airlines for bringing in too many cases.
The loosening of curbs, a day after President Xi Jinping led his new Politburo Standing Committee in a meeting on COVID, cheered markets even as many experts warned that the measures were incremental and reopening probably remained a long way off.
Under the new rules, centralised quarantine times for close contacts and travellers from abroad were shortened from seven to five days. The requirement for three further days in home isolation after centralised quarantine remains.
China will also stop trying to identify "secondary" contacts - a major annoyance for residents of cities who are caught up in sweeping contact-tracing efforts when a case is found - while still identifying close contacts.

"Optimising and adjusting prevention and control measures is not relaxing prevention and control, let alone opening up and 'laying flat', but to adapt to the new situation of epidemic prevention and control and the new characteristics of COVID-19 mutation," the National Health Commission (NHC) said.




China's yuan currency extended gains to a seven-week high after the news and the blue chip CSI 300 Index rose 2.8% in afternoon trade, while Hong Kong's Hang Seng Index jumped more than 7%, its biggest daily gain since March.
The easing comes even as case numbers in China surge to their highest since April, with Beijing and the central city of Zhengzhou seeing record tallies, and numerous cities widened localised lockdowns and other measures, including in the southern metropolis of Guangzhou.
But Bruce Pang, chief economist at Jones Lang Lasalle, said some interpretations of the new rules and what they might mean for prospects for a full opening were "too optimistic".

"The COVID policy will only be fine-tuned in the short term," he said.
The news was greeted with both excitement and wariness among Chinese citizens fed-up with nearly three years of COVID curbs, which are also taking a mounting toll on the world's second-largest economy.
Travel platform Qunar said search volumes for international flights tripled from the previous day.
"It depends on how the localities execute. I'm afraid to be optimistic," said one user on the Weibo social media platform.

Still, the measures were China's most significant specific COVID easing steps to date, and were widely seen as a milestone.

"This set of substantial changes marks the beginning of the end of Zero-Covid, in our view," Citi analysts wrote. "We expect the preparation work for full reopening to accelerate with a quick ramp-up of booster vaccinations in the coming months."

'BABY STEP'

The NHC said it would develop a plan to accelerate vaccinations, which experts say is crucial before the country can begin more fully dialling-back a zero-COVID policy that has made China a global outlier.

Among the new measures is an adjustment of categorisation of COVID risk areas to "high" and "low" - eliminating a "medium" category in an bid to minimise the number of people caught up in control measures.

The new steps include ending a "circuit breaker", under which airlines faced a suspension of flights if they brought in too many COVID-infected passengers, a system that caused frequent cancellations. Still, international flights remain at a small fraction of pre-COVID levels.

"It is a baby step in the right direction," Joerg Wuttke, president of the European Union Chamber of Commerce in China, said of the new rules.
SUGGESTED FOR YOU



"But the big question looming over all of us is when is China ready to actually start a vaccination campaign that gives them the herd immunity to really open up the country?"

Many experts say China is unlikely to begin reopening until after the March session of parliament, at the earliest.

'STAY AT HOME'

This week, cities across China imposed tighter control measures as case numbers surged, although they are low by global standards.

Authorities reported 10,535 new domestically transmitted cases for Thursday, the most since April 29, when Shanghai was battling its most serious outbreak under strict lockdown.

The city of Guangzhou - a manufacturing and transport hub - reported 2,824 new local cases for Thursday, the fourth day in which infections exceeded 2,000.

At least three of Guangzhou's 11 districts have been put under some sort of restriction, and the city's Haizhu district extended a lockdown until Sunday.

"Only one person in each household is allowed to buy daily necessities on a staggered schedule," the government of the district of 1.8 million people said.

However, Guangzhou also said it would immediately release "secondary" contacts from quarantine, under the new rules.

Beijing, Zhengzhou and Chongqing also tightened measures as cases rose.

Zhengzhou reported 2,988 new cases, more than doubling from a day earlier, in a widening outbreak that has sparked chaos at an iPhone assembly plant of Apple supplier Foxconn.

In the southwestern metropolis of Chongqing, cases hit a new high of 783 on Thursday. Some districts on Friday banned restaurant dining and some subway stations were closed.

Beijing reported a record 118 new domestic cases for Thursday, with some parts of the city urging daily testing for three more days. Some Beijing areas have barred entry to public spaces including offices, leisure venues and fitness centres.

(Reporting by Ryan Woo, Tony Munroe, Albee Zhang, Ellen Zhang and Martin Quin Pollard; Additional reporting by Josh Ye in Hong Kong and Jason Xue in Shanghai; Editing by Gerry Doyle, Robert Birsel and Tomasz Janowski)





Reuters Health Information © 2022

"

 

[Arcadian]

There's apparently a very nasty respiratory thing going around. someone I work with ended up in the hospital for a few days..

 

[missy]

"

The latest​

Moderna said its targeted booster shot increases the body’s defense against omicron subvariants.

“In blood drawn from people who received the bivalent booster, omicron-blocking antibody levels shot up 15 times higher than their pre-booster levels,” my colleague Carolyn Y. Johnson reports.

While these data show promising results, it’s unclear if the news will impact the lackluster vaccine uptake. According to the Centers for Disease Control and Prevention, only 10 percent of Americans age 5 and older have received the updated boosters that were rolled out in September.

The federal government kicked off its Vax up America Tour on Monday in an effort to get as many people as possible inoculated with coronavirus booster shots.

According to federal officials, 8 of 10 Americans older than age 55 have a chronic condition — such as diabetes, heart or lung disease, or cancer — that puts them at increased risk of serious illness if they catch the coronavirus or the flu, which has been hitting the United States unusually early and hard. Another virus flourishing right now is respiratory syncytial virus – RSV.

Part of the campaign will focus on getting young Black adults and Black people older than 50 vaccinated by holding events at historically Black college and university football games starting Saturday at Alcorn State University in Mississippi. The Department of Health and Human Services’ campaign will continue working with more than 1,000 community organizations — many in minority or rural communities — to hold pop-up vaccination events at nursing homes, state fairs, Head Start locations and community health centers.

Other important news​

China eased the coronavirus quarantine period for international travelers. According to China’s National Health Commission, the government will require a five-day quarantine followed by a three-day “home health monitoring.”

A cruise ship with 800 people who tested positive for the coronavirus docked in Sydney on Saturday, my colleague Kelly Kasulis Cho reports.
"

 

[missy]

"

COVID Vaccine Mandates in the Spotlight at the AMA's Interim Meeting​

— Sobriety criteria for liver transplant patients also discussed​

by Joyce Frieden, Washington Editor, MedPage Today November 14, 2022


Should states be encouraged to require COVID-19 vaccination for public school and college students once FDA fully approves the vaccines? Members of the American Medical Association (AMA) were divided Sunday on the question.
"By the time these vaccines are fully FDA-approved, that is when we should have a mandate," Frank Dowling, MD, an Islandia, New York psychiatrist who was speaking for the New York delegation, said at a reference committee hearing during the interim meeting here of the AMA's House of Delegates. "We are still in the neighborhood of 270 to 300 people dying per day in the United States from COVID. It's way less than it was, but we are not done. At that pace, that would be 100,000 people per year -- that's still two to five times more people than die per year from the flu."

Mike Lubrano, MD, of Boston, speaking for the Young Physicians section, agreed. "COVID can be a devastating disease to the unvaccinated, and we know that vaccines are safe and they work," he said. "In order for public schools to be truly accessible to all children, including those with conditions that exclude them from vaccine eligibility, we need to ensure that all children in these spaces who can get vaccinated are vaccinated."
But Ross Goldberg, MD, of Phoenix, a delegate from the American College of Surgeons who was speaking for himself, said that now was not the right time to be pushing a vaccine mandate. "In the great state of Arizona, we actually passed a law earlier this year [making it] illegal to mandate the COVID-19 vaccine for schools," Goldberg said, noting that he has been appearing on local media to advocate in favor of vaccination. "Other states are already kind of ahead of the ball on this, and are passing these things. So the AMA now coming out and saying there needs to be a mandate -- I think the timing is off. There are some states where now we physically can't do that because laws have been passed and trust me, they're not undoing this one any time soon."

Randy Easterling, MD, an alternate delegate from Mississippi who was speaking for himself, said that while he personally was a "strong proponent" of COVID vaccinations, "If a resolution such as this passes, it will be used against us in other states that have strong vaccination laws ... to dilute our present vaccination laws."
The committee also heard positive comments on a resolution from the medical student section urging the association to encourage transplant centers to expand their criteria for potential liver transplant recipients to include patients who may not satisfy center-specific alcohol sobriety requirements. "Data show that sobriety requirements for liver transplants do not affect or influence relapse rates, and this requirement could be actively harming patients," said Kylie Rostad, of Toledo, Ohio, an alternate delegate for the Medical Student Section.
"Post-liver transplant patients with alcohol-related liver failure experience significant improvement in mortality. On the other hand, similar patients who were unable to receive a transplant have staggeringly high mortality rates," Rostad said. "While we recognize that organ transplant [involves] exceedingly complex medical management and allocation of a finite resource, we also believe that restrictive sobriety requirements should not play a significant role in the decision for receiving necessary medical treatment for end-stage disease, especially when these patients have strong interpersonal support systems."

Peter Bretan, MD, a transplant surgeon from Novato, California who spoke on behalf of the California delegation and PacWest, supported the resolution, saying that "guidelines and protocols in terms of the standard care in transplant, especially in life-or-death situations, were never meant to be so rigid to exclude patients that might benefit from these life-saving transplants ... Most importantly, they were never meant to replace overall judgment of the surgeon and transplant team."
Delegates also debated a resolution that called on the AMA to declare that "immigration status is a public health issue that requires a comprehensive public health response and solution," and that the association "support the development and implementation of public health policies and programs that aim to improve access to healthcare and minimize systemic health barriers for immigrant communities."
"We are asking immigration to be recognized as a social determinant of health," explained Kamalika Roy, MD, of Seattle, speaking on behalf of the International Medical Graduates Section, which wrote the resolution. "Research shows that immigration is a life event that is negatively linked to immigrants' health. Upon arrival to the U.S., immigrants usually have better health than their American-born peers, which is known as the 'immigrant health paradox.' However, their health declines faster the longer they live in the U.S." due to factors such as limited access to medical care, loneliness, social isolation, socioeconomic conditions, and food insecurity. "Healthcare professionals often do not recognize the complexity and interconnectedness of these issues that might affect immigrants' health," she said.

Tyler Campbell, MD, of Winchester, Ohio, who spoke on behalf of the Great Lakes Delegation, argued for the resolution to be referred to the AMA's board of trustees. "While we do agree that immigration status may indeed be a social determinant of health, we felt, as written, that this was very complex," he said. "Immigration status could include those that are undocumented immigrants, all the way to those that are very affluent ... We felt because of those complexities, and the nuances that are involved with how those factors impact those social determinants of health, we thought referral would be more appropriate."
Corliss Varnum, MD, a delegate from Oswego, New York who spoke for himself, disagreed. "Illegal, legal -- they're still people," he said. "They still need treatment and they are a source of infection -- polio that's never been vaccinated [against], and measles and other diseases that could be prevented. To protect ourselves at least, we need to treat them and protect them."


"

 

[missy]

"

Covid Zero Caution Reigns​

Markets were euphoric on Friday after China announced a raft of changes to its Covid Zero strategy — detailed in a 20-point playbook — that includes shortened quarantine times, the end of a flight-suspension system and reducing mass testing and contact tracing. Investors saw the changes, announced at a time when Covid cases have climbed to a six-month high, as a potential first sign of a shift away from the virus strategy that’s left China isolated for almost three years. But officials moved quickly to quash the idea that they’re giving up on stamping out transmission. “I have to emphasize in particular that strict Covid prevention and control and the optimizing measures must be combined and implemented at the same time,” Chang Jile, deputy director of the NHC’s Bureau of Disease Prevention and Control, said at a briefing over the weekend. China’s large population and other factors mean it can’t “lie flat” like other nations, officials said. That’s fueling expectations that rather than an exit, the changes reflect Beijing’s efforts to optimize the regime to make it more sustainable. Generally, authorities are still very cautious and the new measures are mainly meant to rectify overreactions, according to Standard Chartered Plc. It’s unclear how readily local governments will implement changes. Municipal authorities are still under pressure to eliminate the virus, but in a way that’s more targeted and avoids the widescale disruption to daily life wrought by sudden city-wide lockdowns. Some of China’s megacities may be a template of sorts: Guangzhou and Zhengzhou, which have both seen cases surge, have avoided a complete shutdown and instead imposed more localized restrictions. Residents at a Covid-19 testing truck in Guangzhou, China, on Tuesday, Sept. 20, 2022. Photographer: Qilai Shen/Bloomberg Officials also have to contend with millions of the country’s vulnerable elderly remaining under-vaccinated, with three years of propaganda leaving many Chinese still deeply afraid of the virus. The outlook for travel also remains uncertain. While the end of the flight-suspension mechanism may make it easier to book a trip to China, the labyrinth of local rules around quarantine for travelers — even those moving around domestically — may continue to weigh on the tourism sector. During my flight from Macau to Beijing over the weekend, the passenger next to me said he’d spent a week in the gambling hub to get around onerous restrictions. Traveling from virtually virus-free Macau requires no quarantine time. But he’d been in Guangdong, a current hotspot, and found it impossible to get to Beijing as he was getting a ‘pop-up’ window on his health-code app that meant he was banned from entering the capital. So while there are positive signs that residents may face fewer disruptions in some aspects of their daily lives, there’s clearly still a long way to go toward any meaningful shift away from Covid Zero. — Claire Che

:

 

[dk168]

Covid has hit the area in China where the bench I use is based.
Lockdown has been imposed, and I received an email from my usual contact to inform me that my order will be delayed as they can't make the items as quickly as they had planned.

DK

 

[missy]

Covid has hit the area in China where the bench I use is based.
Lockdown has been imposed, and I received an email from my usual contact to inform me that my order will be delayed as they can't make the items as quickly as they had planned.

DK

Sorry @dk168. I hope everyone recovers and you remain well

There's apparently a very nasty respiratory thing going around. someone I work with ended up in the hospital for a few days..

Yes I posted about this a last week. Please stay safe and well. This might prove to be a challenging winter for many of us

 

[missy]

"

Dispatches from inside the CDC​

Last Thursday, I quietly trailed CDC staffers into a town hall at the public health agency’s Atlanta campus. It was a rare privilege: I’m the only member of the press ever allowed into such a staff meeting. Some eyed me warily, but Director Rochelle Walensky soon diverted their attention. She walked onto the stage in a brown suit and began addressing dozens of employees in the room and another 4,400 who had tuned in remotely. For the next hour, Walensky fielded their questions. I was struck by the ways in which their curiosities mirrored my very own: How did she think the CDC handled its response to monkeypox? Was she optimistic Congress would grant the agency greater authority around the collection of health data? What was keeping her up at night? I had posed these same questions to Walensky a day prior in a sit-down interview. (Watch a video of my conversation with her here.) The trip to Atlanta had actually been rescheduled after Walensky herself contracted Covid and experienced a rebound in symptoms. Even as the CDC winds down aspects of its Covid response and redeploys resources to fight other diseases, the virus continues to take its toll on the agency and the American public writ large. Walensky shared her concerns about a range of respiratory viruses that have been devastating children and the nation’s fragile public health infrastructure. It was already public knowledge that pediatric hospitalizations were climbing due to RSV, but the CDC had also found that babies under 6 months older were increasingly at risk from Covid. A photo of a vintage vaccine ad at the David J. Sencer CDC Museum. Riley Griffin/Bloomberg In recent months, children younger than 6 months old have faced the second-highest rate of hospitalization associated with Covid across all age groups, trailing only behind those ages 65 and up, the CDC said in a new report. Hospitalizations increased eleven-fold for those infants from December 2021 to August 2022, during the time when omicron and its subvariants were dominant. Infants under 6 months old still can't get vaccinated against the virus, so Walensky is moving forward with plans to encourage pregnant mothers to get their Covid shots and boosters. Research has demonstrated that vaccinated mothers can pass on antibodies to their newborns and reduce their risk of hospitalization. This isn't the first time the CDC is urging vaccination for pregnant people in response to an infectious disease crisis. Prior to the 2009, uptake of flu shots among pregnant people was pretty low, around 15%. But in 2009, H1N1, AKA swine flu, caused a particularly bad flu season. Pregnant people were targeted as a key group for vaccination. Rates of flu vaccination among those who are pregnant have gone up since then and the CDC continues to encourage them to get flu shots. Through the end of September, 21% of pregnant people had been immunized for the current flu season. But when it comes to driving Covid vaccine uptake, Walensky knows she faces a tougher road ahead. “People are exhausted,” the director told me. “Covid is not on the front page anymore. People really want to get beyond this.” — Riley Griffin :

 

[missy]

From JAMA

"

Highlights From Infectious Disease Week 2022—COVID-19, HIV, Monkeypox, and Polio​

Melissa Suran, PhD, MSJ
Article Information
JAMA. Published online November 9, 2022. doi:10.1001/jama.2022.17754
Medical News Website




This year’s Infectious Disease Week (IDWeek) highlighted several topics, ranging from evaluations of COVID-19 treatment to updates on the monkeypox outbreak. The conference, which concluded in late October, was a joint meeting of the HIV Medicine Association, the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society, the Society for Healthcare Epidemiology of America, and the Society of Infectious Diseases Pharmacists.

Adarsh Bhimraj, MD
For an inside look, JAMA spoke with IDWeek’s IDSA Chair Adarsh Bhimraj, MD, who is also director of Infectious Diseases Fellowship and Education at Houston Methodist Hospital. The following is an edited version of that conversation.
JAMAuring IDWeek, there were several discussions as well as studies presented about COVID-19 therapies and treatments. Are there any new trials for COVID-19 or innovative methods for evaluating treatments?
Dr Bhimraj:What caught my attention was a whole session dedicated to adaptive platform trials. During the COVID-19 pandemic, there was a lot of uncertainty, and the epidemic was evolving rapidly, so we needed to come up with trial methodology where you could evaluate multiple treatment agents. And as you learned more about the pandemic as it evolved, we had to incorporate that into the trial design. There are 2 trials I want to highlight: one is ACTIV-6 [Accelerating COVID-19 Therapeutic Interventions and Vaccines]. It evaluated outpatient mild to moderate disease and 3 agents: ivermectin, inhaled fluticasone, and low-dose fluvoxamine. They did not show any significant differences in symptom relief [compared with a placebo]. There’s a lot of ivermectin use at extremely high doses, and figuring out what not to use, especially in mild to moderate disease in outpatient cases, is important.

At the other extreme are patients who are severely ill to the point that they need oxygen or even get admitted to the ICU [intensive care unit] with COVID-19. ACTIV-1 is a randomized platform trial that evaluated COVID-19 treatment in these populations. What it showed is that abatacept and infliximab decreased mortality. The primary end point in terms of time to recovery did not reach statistical significance, but there was a trend toward a benefit. Why is this important? Patients admitted to the hospital have an aberrant inflammatory response, and we already have certain treatments that have been shown in earlier trials to be effective.
JAMA:On a similar note, what new research was presented about COVID-19 vaccination?
Dr Bhimraj:As variants emerge, we have the question: Are newer vaccines, like the bivalent vaccines, effective? Moderna presented data about the BA.1 bivalent vaccine. If you look at the bivalent vaccine compared to the original vaccine, the safety profile was equivalent or even slightly better in certain areas. For people who got the booster, the bivalent booster vaccine had much higher titers of neutralizing antibodies [than the prototype booster had against Omicron]. We want clinical outcomes, but as the pandemic evolves, we can’t really wait until all the clinical outcome studies are done. So it’s reassuring that the bivalent vaccine is not only safe but also has a robust immunogenic and protective response.
JAMA:Another infectious disease that made headlines this year is monkeypox. Could you please share a brief update on the outbreak?
Dr Bhimraj:The latest data were presented by the CDC [Centers for Disease Control and Prevention] at IDWeek. There are a little over 70 000 cases throughout the world. The good news is even though monkeypox was on the rise, it’s actually going down right now. The response was a little slow to begin with, but I’m still impressed with how vaccination efforts were mobilized. Monkeypox, and polio as well, are neglected tropical diseases. They teach us a very important lesson: that we not only live in a global village, but we live in a global metropolis. It doesn’t take a lot for these infections to be introduced from one country into another country and spread rapidly. We need surveillance of these diseases and we also need mechanisms to respond appropriately.
JAMA:You mentioned polio. What new information about the outbreak was presented at the conference?
Dr Bhimraj:Polio is something we think is a thing of the past. The first recent case of polio was reported in an unvaccinated adult in New York State. I think it was brilliant that the clinicians who were taking care of the patient said, “This is something unusual; we have to report it to health authorities.” The New York State Department of Health also investigated with the CDC to figure out that this is a polio case. And the strain of the polio is not a wild type: this is a strain that comes from oral vaccines. Oral polio vaccines are not used in the US but are still used in other parts of the world. A similar strain was detected within the wastewater systems of UK and Israel as well. Again, this emphasizes that we think we have conquered a particular disease, but as long as that infection is prevalent in other parts of the world, it’s always possible that it can make a resurgence or a reemergence. If you look at vaccinations, most adults don’t get vaccinated for polio. Most of the vaccination is in childhood unless you’re at a higher risk by traveling. Like I talked about with monkeypox and COVID-19, we need systems in place for surveillance. We need systems in place for vaccination and other efforts for potentially emerging and new diseases.
JAMA:Let’s also talk about what’s new on the antifungal and antibiotic fronts. There were some interesting studies presented at IDWeek ranging from histoplasmosis to pneumonia treatment.
Dr Bhimraj:One study that stood out for me is a trial on liposomal amphotericin B to treat histoplasmosis, a fungal infection. Traditional treatment includes IV [intravenous] amphotericin, which is an expensive drug and logistically takes a lot of effort over 2 weeks. So, what these investigators did is they used a high dose of liposomal amphotericin as a single dose and compared it to traditional treatment. Surprisingly, in terms of safety as well as efficacy, it didn’t look that different. This is a very promising study because in resource-limited settings, I think this will be a game changer. I do want to add the caveat that this is a phase 2 study.

From a diagnostics point of view, there’s another study called the INHALE WP3 study. This was a huge study where the investigators were able to do testing right at the site. So they went to ICUs where patients were admitted with pneumonia and did multiplex PCR [polymerase chain reaction] testing where the clinicians were told what organism was causing the pneumonia—that was the intervention arm. In the control arm, the physicians could treat the patients with routine care, where they could send the test for cultures, but it takes time to come back. Reaching the right diagnosis using the tests resulted in increased appropriate antimicrobial use. The investigators also looked at whether using a test results in cure; does it result in clinically meaningful outcomes? Surprisingly, it did not. If anything, the arm that did not use the rapid testing resulted in slightly better cure. Often, we introduce new tests, but does it translate into outcomes that matter for the patient? This is one of the few studies that attempted to answer this.
JAMA:The conference also highlighted new findings related to treating urinary tract infections, especially in terms of preventing recurring infections. Could you discuss some of those results?
Dr Bhimraj:The ALTAR [Alternative to Prophylactic Antibiotics for the Treatment of Recurrent Urinary Tract Infections in Women] trial presented at the conference compared methenamine, which is, for lack of a better word, a urinary antiseptic. Using methenamine when compared to prophylactic antibiotics was similarly effective at preventing recurrent urinary tract infections. This is important because the more antibiotics you expose to a patient, the more likely the bacteria they’re colonized with can become resistant to those antibiotics. So methenamine was not inferior to prophylactic antibiotics, but the added advantage of methenamine is it doesn’t result in use of broad-spectrum antibiotics, which might lead to the resistance of drug-resistant bacteria. It also reduces the amount of antibiotics used.
JAMA:And what were some of the new trials and treatments presented for Staphylococcus aureus infections?
Dr Bhimraj:One of the antibiotics, ceftobiprole, has been around for a couple of years. It’s not only important to introduce novel antibiotics, but also to look at efficacy and safety. One of the trials that was presented is called the ERADICATE trial, which compared ceftobiprole to daptomycin with and without aztreonam for Staphylococcus aureus bacteremia. Ceftobiprole was noninferior in terms of cure and also in terms of complications from Staphylococcus aureus bacteremia and side effects.
JAMA:An emerging area of interest is microbiome therapy to treat as well as prevent certain diseases. What were some of the studies and discussions at IDWeek regarding microbiome-based therapeutics?
Dr Bhimraj:One of the presentations was about SER-109. This has been published in The New England Journal of Medicine and recently in JAMA. The investigators took spores of firmicutes in a capsule form and gave it to patients who had a recurrent C diff [Clostridioides difficile] infection. Administering SER-109 showed a significant reduction and recurrence of C diff in patients who were already treated. Not only did it decrease C diff relapse, but in a post hoc analysis, using SER-109 resulted in a lesser amount of antimicrobial resistant genes. The alternative, if you’re using antibiotics, might result in more antimicrobial resistant genes within the gut flora.
JAMA:I’d like to dedicate some time to HIV treatment. The conference featured research on switching from daily to monthly medication to help control HIV, and there was also research about a new vaccine for hepatitis B, as liver infection is a major concern in the HIV community. According to data from the CDC, about 10% of individuals living with HIV are also infected with the hepatitis B virus. Could you discuss some of the IDWeek research on those topics?
Dr Bhimraj:We have come a long way with HIV treatment. You used to take several pills every day, and taking once-a-day pills was an advancement. Now we have long-term treatments where you can take medication once a month, and newer studies show even once every 2 months could be effective. The FDA [US Food and Drug Administration] approved the combination of rilpivirine and cabotegravir in 2021. What was presented demonstrated real-world effectiveness of the HIV treatment once a month and once every couple of months, which will significantly increase the convenience and compliance with taking the medications.

Another study, like you said, is about hepatitis B. If you look at the regular vaccines that we usually use, you have a good seroresponse in immunocompetent individuals, but people who have HIV—especially with low CD4 [T-cell] counts or high viral loads—do not have a good serological response to the hepatitis B vaccine. So for this preliminary study, the investigators took the hepatitis B vaccine that had an adjuvant called a CpG [cytosine phosphoguanine] and looked at it in HIV patients. Almost 100% of patients, depending on which way you look at the analysis, had seroprotection at 4 weeks. I think this is an important study because adding an adjuvant like CpG might be the solution to better seroprotection rates, especially in immunocompromised patients like those with HIV.
JAMA:Inequities remain when it comes to health care access and outcomes for both COVID-19 and HIV. What were some of the IDWeek discussions surrounding such issues?
Dr Bhimraj:That is a very important question. We had a session on long COVID and how there are inequities or disparities among communities of color, and the closing plenary was also about that. And there are gender inequities as well as inequities in rural and urban settings. Not only do we need better mechanisms to look at these inequities, but we need to analyze the underlying social and structural determinants of these inequities and address them adequately. Take COVID-19: even though there are disparities that still exist in outcomes, in certain communities of color the vaccination rates improved. But there’s a lot that needs to be done going forward, and the only way to do it is having systematic programs and policies in place.

Article Information
Published Online: November 9, 2022. doi:10.1001/jama.2022.17754
Conflict of Interest Disclosures: Dr Bhimraj reported receiving an honorarium in 2022 for participating as a clinical content expert in a public meeting organized by the Institute for Clinical and Economic Review. He also reported chairing IDSA’s rapid living guidelines on COVID-19 in a volunteer capacity with no financial remuneration.


"

 

[missy]

"

November 8, 2022

Second COVID-19 Booster Increases Protection for Nursing Home Patients​

Bridget M. Kuehn, MSJ
JAMA. 2022;328(1:1800-1801. doi:10.1001/jama.2022.18451
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2793699


Receiving a second COVID-19 booster increased protection against severe outcomes, including hospitalization and death, by 74%, a multi-institution team of researchers found.

iStock.com/Aliaksandr Litviniuk
The investigators analyzed data from about 9600 residents at 196 nursing homes operated by Genesis Health Care in 19 states. The authors compared outcomes in a subset of 1902 residents who received 2 doses of an mRNA vaccine against SARS-CoV-2 and 2 booster doses and a matched set of controls who received the original vaccine series and 1 booster dose. All patients in the 4-dose group received their second booster dose between March 29, 2022, and June 15, 2022, and researchers monitored patient outcomes through July 25, 2022.
Vaccine efficacy against SARS-CoV-2 infection was about 26% at 60 days after the second booster. Vaccine efficacy against hospitalization alone was about 60% and death alone was about 90%. The results were similar to a study conducted in Israel that found a 34% reduction in SARS-CoV-2 infections, a 64% to 67% reduction in hospitalizations, and a 72% reduction in death among long-term care residents who received 4 mRNA vaccine doses compared with 3 doses.
According to the authors, the new study adds valuable evidence about the benefits of a second booster for nursing home residents after the Omicron strains, including BA.4 and BA.5, became predominant.
“The results support the importance of continued efforts to ensure the nursing home population is up to date on recommended COVID-19 vaccine booster doses, including the newly authorized bivalent COVID-19 vaccine,” the authors wrote.


"

 

[missy]

"

State of Affairs: November 16, 2022​ KATELYN JETELINA NOV 16

The respiratory illness storm ravages on. And it’s only November. Here is where we are with the “triple threat.”

RSV​

Cases of RSV continue to skyrocket. Data shows we are testing a lot, though, as test positivity rates are not as high as in 2021. This is likely attributed to increased knowledge, which is good news. In addition, there are hints that RSV is peaking. With RSV, antigen test positivity rates usually peak before PCR, and that’s what we are seeing now. Cases may soon follow.

​

(Source: CDC)
Historically, the RSV season lasts 5 months. It will be interesting to see how the holidays impact RSV patterns, though. Typically RSV peaks in January, but because it has arrived so early, we are in new viral dynamic territory. There’s no doubt that social networks will change next week due to Thanksgiving. For example, we will see family that we don’t typically see. This will open up new pathways for transmission, and RSV numbers may therefore continue to rise.

Influenza​

Flu is right behind RSV and coming in hot; it’s earlier and steeper than previous pandemic and non-pandemic years.

​

(Source: CDC)
We certainly see regional variability of the flu. A number of states in the South and the Atlantic seaboard, for example, have the highest activity level color that CDC records—purple in the map below. (The first time CDC used a purple color was in Louisiana in 2019, when they added it to the scheme due to very high levels.) This is causing flu surveillance at Johns Hopkins, for example, to go off the charts as seen below.

​

(Source: CDC)

​

(Source: Andrew Pekosz)
There is good news from the Southern Hemisphere among countries that just concluded their flu season. Chile, for example, found the flu vaccine is a good match for the current strain. They are reporting a 49% efficacy rate. But only 28% of Americans are vaccinated against the flu. This is almost 10 percentage points lower than pre-pandemic rates, which is frustrating.

COVID-19​

Interestingly, for the first time during the pandemic, there are more than 300 subvariants circulating, and not one is dominating globally. This isn’t stopping the virus from causing waves, though. SARS-CoV-2 is currently creating two global hotspots: Western Pacific and Southeast Asia. In South Korea, for example, we see an increase in cases and hospitalizations due to the variant soup (lots of lines of color in the figure below are increasing, as opposed to just one or two lines of color that we’ve historically seen).

​

(Source: Moritz Gerstung)
Other areas across the globe are starting to tick upward, including admissions in South Africa and Western Europe. Similarly, these upticks are not due to one variant but rather a mix of Omicron subvariants, waning immunity, weather, and behavior change.

​

(Source: Jean Fisch)
The real headscratcher is that the U.S. wastewater continues to plateau, but given previous patterns, a wave should have started by now as BQ.1 accounts for more than 50% of cases. A lot of eyes are on the West, too, as a new Omicron subvariant—BN.1— is growing.

​

Purple= Midwest; Pink= South; Orange=Northeast; Green= West. (Source: Biobot Analytics)
Given trends in Europe, it is still very likely that the U.S. will have a COVID-19 wave. But, overall, this could be a good sign that we finally have an immunity wall that is challenging the movement of COVID-19, regardless of labs showing subvariants can partially escape immunity. We need to hold off on sweeping conclusions—like whether this pandemic is over— until this winter plays out.

Implications​

The convergence of these diseases has three important implications:

1. Impact on hospital systems. The hospitals, and in particular pediatric hospitals and emergency departments, are hanging. by. a. thread. Every pre-pandemic winter, pediatric hospitals were overwhelmed. This year the unique combination of circumstances is creating terrible strain, which has many implications, including the quality of care for everyone. We need to fix this on a systematic level.
2. Risk of co-infections. Someone can be infected with two viruses at the same time. In fact, the first death from RSV and flu co-infection was reported in a child under 5 years old in California.
3. Lessons not learned? I had hoped we would have applied lessons from COVID-19 to other diseases, like masking, staying home while sick, and getting vaccinated. Unfortunately, it doesn’t seem like this is happening. After 2.5 years of a pandemic, the public (and leadership) is just in a different state of morale, and the willingness to take preventative steps seems to be lower.

Bottom line​

“Normal” viruses are continuing to show their muscle, and the seasonal virus repertoire now includes COVID-19. We are very concerned going into winter, as this situation is already applying massive pressure to hospital systems. Time will tell how the next few months play out.

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Who is dying from COVID19? ​

KATELYN JETELINA NOV 18

Until now, the CDC has relied on Morbidity and Mortality Weekly Report—an internal scientific publication journal—to communicate COVID-19 science throughout the pandemic. But this pipeline is too slow for crisis communication. We need rapid analyses to guide evidence-based decision-making.

The WHO and countries like the U.K. have used technical reports throughout the pandemic to publicly share data they were seeing in real time, even if imperfect. This achieves many goals (transparency, proactive communication) but also allows for laser focused, data-driven strategies for innovative problem solving. The CDC leveraged technical reports (eventually) with monkeypox. It’s about time we use this strategy with COVID-19, too.

This week, CDC released their first COVID-19 Technical Report. This report provided a key puzzle piece we’ve been missing throughout the pandemic: Who is dying? Answering this question is the first step in moving the increasingly stubborn needle of COVID-19 mortality in the U.S. (We still have excess death and COVID-19 is still poised to be the 3rd leading cause of death in 2022.)

Below are a few key findings that I pulled from the report.

Signs of improvement​

Fewer people are getting severe disease from infection. People who are hospitalized are now less likely to go to the ICU or be put on a ventilator—both metrics have more than halved since Delta. This means the risk of death has significantly declined. This is great news and unsurprising (although I was surprised how much this changed from early Omicron to later Omicron).

​

Crude Mortality Risk per 100 Patients Hospitalized Primarily for COVID-19 for Multiple Patient Groups, by Predominant Variant Period, United States, July 2021–June 2022

A shift in who is dying​

Age. Those 65 years and older are contributing more and more to the proportion of deaths over time. This is likely due to a few things: younger people are now vaccinated; older people have weaker immune systems; and older people are more likely to have comorbidities. Targeting communication and resources to older adults will be key to further reducing mortality.

​

Distribution of Provisional COVID-19–Related Deaths by Age Group, United States, Weeks Ending February 22, 2020–October 1, 2022. Source Here.
Sex. Men are still dying more often than women. There may be some hormone and genetic factors at play here. (Also, men, go to a doctor if you feel sick.)

Race/ethnicity. Disparities have narrowed. Among those under 65, mortality is highest among American Indian/Alaska Natives. Among aged 65 and older, it’s highest among Non-Hispanic White. These demographics shift frequently, though, as differences are small.

Vaccines are effective if you’re up-to-date​

Vaccines have saved countless lives. However, it’s increasingly clear that those over 50 must be up to date. Today, 1 in 2 deaths among those over 65 had one booster. (While ~5% of adults 65 and older remained unvaccinated, they comprised 22% of deaths—a disproportional amount.) Given that only 29% of older adults have their Fall booster means we have a lot of work to do.

​

COVID-19–Associated In-Hospital Deaths by Adult Age Group and Vaccination Status—COVID-NET, United States, May–August 2022 (Source CDC)

Shifts in where and how deaths occur​

Yes, people are still dying from COVID-19. In fact, the vast majority of deaths have COVID-19 listed as the underlying cause of death. This is opposed to a contributing cause of death (COVID-19 infection putting stress on an already failing heart) or incidental death (e.g., from trauma and they happen to have COVID-19).

​

Proportion of Deaths with COVID-19 as the Underlying Cause of Death by Year and Age Group, United States, 2020–September 2022. Source CDC Here.
There has been a substantial shift in where people are dying. People are dying less in hospital settings, and more in hospice, at home, or in nursing homes. There are a lot of complicated reasons for this, including people who survived initial infection but continued to suffer COVID-19–related long-term health effects.

​

Provisional COVID-19–Related Deaths among Persons Aged ≥65 Years by Month and Place of Death,* United States, January 2021–September 2022. Source here.

Treatment distribution is suboptimal​

People over the age of 80 are less likely to receive Paxlovid than those under 65. This is a huge problem and may be for several reasons—medication contraindications (whether they are true contraindications or not), ageism, lack of clinician knowledge, and lack of access to treatment. We need to fix this and it should be a priority.

​

Treatment with Outpatient COVID-19 Medications by Age Group, PCORnet, United States, April–July 2022. Source: CDC
Among immunocompromised patients, 1 in 2 do not get medical treatment. This is even more concerning given that monoclonal antibodies are not effective against the newest of Omicron variants. In other words, that maroon color below will be removed for patients very soon.

​

Treatment with Outpatient COVID-19 Medications* Among Patients with Immunocompromising Conditions, PCORnet, United States, April–July 2022

Bottom line​

To remove COVID-19 as a leading cause of death we need to focus on whois dying and why. To me, it’s clear that we need targeted communication, resources, and efforts to reach this goal, even given a landscape peppered (drowning?) with pandemic fatigue.

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[missy]

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Monoclonal Antibodies May No Longer Be a Match for Emerging COVID Strains​

— Evusheld, bebtelovimab losing potency as circulation of BQ.1, BQ.1.1 grows​

by Ingrid Hein, Staff Writer, MedPage Today November 18, 2022

Tixagevimab/cilgavimab (Evusheld) and bebtelovimab are likely ineffective against approximately 60% of currently circulating Omicron variants, creating a big gap in protection, particularly for immunocompromised individuals, researchers from a Harvard Medical School-led consortium said at a briefing on Thursday.
This is a "big loss," said Jacob Lemieux, MD, PhD, of the Massachusetts Consortium on Pathogen Readiness and Massachusetts General Hospital in Boston, noting that tixagevimab-cilgavimab has become an extremely important tool to ward off severe COVID and death in immunocompromised patients.

Tixagevimab-cilgavimab -- which was granted an emergency use authorizationin December 2021 as pre-exposure prophylaxis (PrEP) for COVID-19 in immunocompromised individuals and those with a history of a severe vaccine reaction -- has lost potency against BQ.1 and BQ.1.1, as well as BA.4.6, BF.7, BA.5.2.6, and BA.2.75.2. As of November 12, these variants make up about 60% of the current circulating Omicron variants.
Bebtelovimab -- which was authorized for emergency use by the FDA in February for non-hospitalized patients with mild to moderate COVID-19 who are at risk for developing severe disease -- has lost its potency against the subvariants BQ.1 and BQ.1.1, which are currently spreading in the U.S., because they contain spike K444T and R346T substitutions.
"These are our last functional monoclonal antibodies," Lemieux noted. "So I think it's fair to say that the virus has outrun the current generation of monoclonal antibodies. This race probably will continue -- hopefully there'll be some new products in the pipeline."

Consortium co-leader Jeremy Luban, MD, of the University of Massachusetts Chan Medical School in Worcester, pointed out that patients with cancer receiving active treatment, transplant recipients, and those receiving immunosuppressive therapy are all going to feel the loss of these effective drugs.
"If you know anyone who has cancer or is immunocompromised for some other reason, it's pretty scary not having this," he said. "It's a big problem."
Recommendations from the NIH COVID-19 Treatment Guidelines Panel were recently updated to reflect the lack of alternative options for PrEP and the waning efficacy of bebtelovimab in the face of these emerging strains.
"The panel continues to recommend the use of tixagevimab plus cilgavimab as PrEP for eligible individuals," panel members wrote. However, the decisions to use the drugs should be based on "the regional prevalence of the resistant subvariants, the individual patients' risks, the available resources, and logistics."

Furthermore, people receiving the treatment, "should take precautions to avoid exposure to SARS-CoV-2," they added.
The panel only recommends bebtelovimab "when the majority of circulating Omicron subvariants in the region are susceptible."
However, one of the challenges is knowing how to treat a patient when you don't know what variant they have, said consortium co-leader Kathryn Stephenson, MD, MPH, of Beth Israel Deaconess Medical Center in Boston. "It's been pretty much one variant replaces the one before in a slice of time, so you almost always know [what variant someone has]. These days, it's a little more interesting in the sense that there's more diversity of virus circulation or variants and it's become really relevant."
"It will be interesting to see if we can have faster diagnostics for sequencing -- it would be nice to know in real time" what my patient has, she added. "But that's not something in clinical practice we typically do."

Vaccination is still the most effective tool out there, Stephenson said. "Now that most people in the U.S. have had a primary vaccine series, their risk of progression to severe disease has gone down."
The bigger problem is with immunocompromised individuals, she noted. "We're going to have to go to other things because the monoclonals are not going to be useful for us for now."
According to the NIH panel recommendations, ritonavir-nirmatrelvir (Paxlovid) and remdesivir (Veklury) remain the preferred therapies (in order of preference) for patients who do contract COVID-19 and are at risk of severe disease.

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[missy]

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Today's must-reads​

Covid Zero returns to a Chinese city that was rumored to be a test case for reopening, while Beijing reported the first virus deaths in months. China’s swelling outbreak is creating a make-or-break moment for leaders’ approach to the pandemic. Three major pharmaceutical companies have limited supply of a popular alternative for the antibiotic amoxicillin due to a shortage.

​ ​ ​ ​ Bananas Breakthrough​

Competitors in a Hong Kong trail race on Nov. 13 made pandemic history by eating bananas. For the first time since the city implemented Covid Zero policies that largely cut itself off from the world, participants could eat mid-race snacks, albeit with restrictions: no oranges, no PB&J sandwiches, just bananas, which had to be consumed in silence and away from the distribution areas. The banana breakthrough is both a sign of Hong Kong slowly reopening and a reflection of the maddening web of rules still in place. Since taking office in July, Chief Executive John Lee — who has just tested positive after returning from the Asia-Pacific Economic Cooperation forum in Thailand, where he mingled maskless with global leaders including Chinese President Xi Jinping — has eased some of the toughest curbs. He’s ended flight bans for airlines, lengthy hotel quarantine for incoming travelers and mandatory stays at the notorious Penny’s Bay isolation center. But Hong Kong has retained mask mandates, social-distancing rules and other policies that critics say aren’t based in science. “Hong Kong presents a hodgepodge of rules that require a lot of effort to comply with,” said Johannes Hack, president of the German Chamber of Commerce in Hong Kong. A runner eats a banana during a trail running race in Hong Kong, China, on Nov. 13, 2022. Photographer: Lam Yik/Bloomberg Most contentious is the rule banning incoming travelers from restaurants and bars for at least three days. The government recently tweaked the policy, announcing that tourists traveling in groups could eat in partitioned areas in designated restaurants even within the three-day period. Industry executives aren’t hopeful that the change will help and want the waiting-period dropped for all arrivals. The government is asking for patience. Hong Kong can’t just scrap all the remaining restrictions, since that would likely mean giving up on the goal of reopening the border with the rest of China. Of course, Bejing wasn’t willing to reopen the border even when Hong Kong had no Covid cases, as opposed to the thousands who now test positive every day, so achieving that goal will be challenging. For now, Hong Kong is taking more small steps toward normalization. Late last week, the government said incoming travelers would now only need to take two PCR tests in their first week in town, down from four. But that's still two more than most of the rest of the world. — Bruce Einhorn

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[missy]

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What Are the Implications of Uncontrolled Infectious Diseases?​

Authors: News Author: Lucy Hicks; CME Author: Charles P. Vega, MDFaculty and Disclosures
CME / ABIM MOC / CE Released: 11/18/2022
Valid for credit through: 11/18/2023

The world continues to be concerned regarding further mutations affecting the SARS-CoV-2 virus. The Omicron virus remains the predominant variant worldwide in early fall 2022, and a study by Ou and colleagues evaluated the genetic signature of Omicron. Their results were published in the April 26, 2022 issue of Nature.[1]

Omicron BA.1 was found to have 18 core mutations of the SARS-CoV-2 spike protein gene sequence, and BA.2 was found to have 27 such mutations; however, only 15 of these mutations were specific to Omicron. The BA.1 variants was more genetically similar to the Alpha variant of SARS-CoV-2 compared with later variants. The changes noted in Omicron variant could assist the virus in resisting the immune system and gaining entry into bronchial epithelial cells compared with previous variants.

The world now waits with apprehension at the possibility of a new pandemic, this time with monkeypox, but a monkeypox pandemic similar to the COVID-19 pandemic seems highly unlikely given the much lower infectivity rates of monkeypox. Nonetheless, the current article by Johnson and colleagues rings the alarm that allowing monkeypox to slowly spread unabated may result in disaster.

Study Synopsis and Perspective​

Monkeypox cases are declining in the United States and the United Kingdom, but experts are urging the public to continue efforts to stanch the spread of the virus. Continued transmission of monkeypox provides more opportunities for the virus to the mutate, according to Philip Johnson, PhD, an assistant professor of biology at the University of Maryland, College Park, Maryland, and colleagues.

"Just because a disease like monkeypox appears to be controllable does not mean it will stay controllable," wrote the authors in a correspondence published October 8 in The Lancet.[2]

When case numbers are lower -- and therefore less of a public health concern -- viral transmission chains can be longer without causing alarm, Johnson explained.

"The more generations of transmission, the more opportunities there are for mutations to occur," he told Medscape Medical News.

Although it is difficult to anticipate how mutations can affect a virus, these changes in genetic code could be advantageous to the virus, making it more transmissible from human to human and therefore much more difficult to control.

This applies to any virus. The large Ebola outbreak from 2013 to 2016 is an example; a retrospective analysis[3] found that specific amino acid changes in the Ebola virus increased growth in human cells and may have made the virus more infectious. More recently, the Delta and Omicron variants of SARS-CoV-2 each contained mutations that were associated with higher transmissibility. A recent study[4] by Isidro and colleagues suggested that monkeypox appears to be mutating faster than expected, although it is not clear if these genetic mutations have changed the virus' behavior.

Zoonotic infections, or viruses that originate from nonhuman animals, at first are expected to be less adapted to people, but that can change over time. When a virus continues to jump from animals to humans -- as monkeypox has done since it was first identified in humans in 1970 -- chances are it will gain a mutation that allows it to spread more effectively between people, said Rachel Roper, PhD, a professor of microbiology and immunology at East Carolina University, Greenville, North Carolina. She was not involved with The Lancetarticle.

"We discounted monkeypox; we didn't pay much attention to it because it had not been that big of a problem," she said in an interview with Medscape. "We think this virus has been circulating now since 2017 and we really just realized it in May."

Although monkeypox received global attention this past summer, the outbreak is now receiving less news coverage, and the public's attention may be waning. Furthermore, the US Congress just dropped billions of dollars from a short-term spending bill that would have provided additional COVID-19 and monkeypox funding.[5]

Although new cases are trending downward, now is not the time to take our foot off the gas, Johnson and colleagues warned.

"The epidemic is far from over, and continued drive toward elimination is essential," the authors wrote.

Because the virus exists in rodent populations in areas of central and west Africa, it is not possible to eradicate monkeypox as we did smallpox; however, "we could, through vaccination, eliminate any significant human to human transmission," Johnson said.

Johnson also urged a more proactive approach to combating emerging infectious diseases in the future.

"We wrote this article to raise awareness about the importance of dedicating resources to controlling these diseases all the way down to ideally elimination in the countries where they develop, and not just waiting until [these diseases] reach wealthier countries," he said.

Roper agreed that a more global perspective is needed in monitoring and controlling zoonotic disease, but resources are limited.

"The problem is there are a whole bunch of virus groups and a whole bunch of viruses jumping into humans all the time," she said. "We can't predict which virus group is going to be the next one with a big hit. I worked on SARS-CoV-1 back in 2003 to 2009, and I would have predicted that a virus from some other group would have jumped into humans next, before COVID hit," she added.

Johnson acknowledged that it is hard to know where to focus public health resources, considering the hundreds of thousands of zoonotic viruses that may exist. He thought the best approach was to target emerging diseases that already appear to have extended transmission chains, "not just things that are hopping from animals to humans and sputtering out and disappearing, but diseases that appear to have any sustained human to human transmission."

Johnson and Roper report no relevant financial relationships.

Study Highlights​

• The monkeypox virus currently in circulation has a reproductive number slightly greater than unity, meaning that 1 case is unlikely to infect more than 1 additional person.
• Ecologic degradation has led to more human contact with zoonoses, including Ebola virus and SARS-CoV-2, which are both encountered in bats. Monkeypox virus has a rodent host.
• A zoonosis is, by definition, less competent in transmission among human hosts and has to adapt to become more transmissible from person to person.
• The authors of the current review suggested that this low reproductive number lends itself to faster evolution of a virus when the case numbers remain low. Models suggest that when an initial human reproductive number approaches 1, the likelihood that genetic mutation will save the virus from extinction among humans increases.
• A pathogen with a lower reproductive number has longer chains of transmission, which can promote a higher rate of mutations.
• Monkeypox has been known for decades as an emerging infection with a reproductive number less than 1. The authors of the current review suggested the application of ring vaccination to control the outbreak.
• Ring vaccination has been used effectively against Ebola virus and involves vaccination of the index case, plus contacts with the index case, plus contacts of those contacts.
• Nevertheless, the incidence of monkeypox in the United States and Europe has declined recently. This might be due to behavioral changes plus higher rates of vaccination, but the authors strongly suggest that further viral suppression is needed at this critical juncture.

Clinical Implications​

• In a previous study by Ou and colleagues of the genetic signature of Omicron variants of SARS-CoV-2, Omicron BA.1 was found to have 18 core mutations of the spike protein gene sequence, and BA.2 was found to have 27 such mutations; however, only 15 of these mutations were specific to Omicron. The BA.1 variants was more genetically similar to the Alpha variant of SARS-CoV-2 compared with later variants.
• Models demonstrate that zoonotic viruses with a reproductive number less than 1 are more likely to mutate and become more transmissible among humans. The authors of the current study, Johnson and colleagues, suggest that ring vaccination could reduce the impact of the current outbreak of monkeypox.

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[missy]

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The latest​ Lab-made coronavirus treatments are losing their effectiveness, and scientists are racing to develop therapies that are “more potent and more resistant to new variants,” my colleague Mark Johnson reports. “Some monoclonal antibodies have been rendered largely ineffective as the virus has mutated; others are expected to become so this winter if a wave of new omicron subvariants comes to dominate the pandemic landscape,” Johnson writes. Immunocompromised people and those unable to get a coronavirus vaccine rely on these treatments. The waning effectiveness of these remedies puts immunocompromised patients at risk of contracting the virus or developing severe illness. ​ ​ ​ ​ Oregon Gov. Kate Brown (D) tested positive for the coronavirus after a recent trip to Vietnam. Brown was attending the Vietnam-U.S. Trade Forum on Thursday. “After returning from Vietnam, Dan [her husband] and I have tested positive for COVID-19. We are recuperating at home and, while this changes our Thanksgiving plans, we are grateful for effective vaccines and boosters that are helping ensure our symptoms don't become serious,” the Oregon governor tweeted Saturday. Rising cases of influenza, respiratory syncytial virus (RSV) and covid-19 are overwhelming many hospitals in the governor’s home state. In September, Oregon lawmakers approved $40 million in emergency funding to help alleviate the overcrowding. ​ ​ Other important news​ China eased its coronavirus rules, and residents are confused and anxious. “The reaction to China’s most significant easing of coronavirus controls has been a jumble of conflicted priorities and public sentiment since Beijing announced the changes a week ago,” Christian Shepherd and Lyric Li of The Washington Post write. My colleague Teddy Amenabar writes on how to differentiatebetween RSV, the flu and covid-19.​

​

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[missy]

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Australia Recommends Against Fifth Vaccine Dose as Fresh Covid Wave Builds​

By Lewis Jackson
November 16, 2022




SYDNEY (Reuters) - Australian health authorities have recommended against getting a fifth COVID-19 vaccine shot, even as they urged those eligible to sign up for their remaining booster doses as the country's latest COVID wave grows rapidly.
Average daily cases had been 47% higher last week than the week before, said Health Minister Mark Butler at a press conference on Tuesday, announcing new vaccination recommendations. But cases remain 85% below the previous peak, of late July.
Butler said the Australian Technical Advisory Group on Immunisations (ATAGI) had recommended against a fifth dose, or third booster, after evidence from Singapore's recent wave showed that severe illness and death were rare among the vaccinated and that a fifth shot had minimal impact on virus transmission.
"ATAGI has considered international evidence as well as the local data around vaccination numbers, as well as case numbers in the pandemic and decided not to recommend a fifth dose," said Butler.

"They noted that severe disease and death during that wave in Singapore was very rare for people who had had at least two doses of vaccine for COVID."




New booster recommendations will be made early next year ahead of the southern-hemisphere winter.
Butler urged those yet to get the recommended number of shots to do so, with 5.5 million Australians, roughly a fifth of the population, yet to receive a third dose despite being eligible.
Butler also accepted ATAGI recommendations that Pfizer's Omicron-specific vaccine be approved as a booster dose for adults; 4.7 million doses will arrive ahead of a rollout due to begin on Dec 12.

The company's vaccine for children aged six months to five years will also be approved for use on the severely immunocompromised.
Speaking alongside Butler, Chief Medical Officer Paul Kelly said the Singaporean experience suggested the current wave would peak soon and that cases would then drop quickly.
(Reporting by Lewis Jackson; Editing by Bradley Perrett)

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[missy]

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The Right Indoor Relative Humidity Could Ward Off COVID​

Ralph Ellis
November 21, 2022

While having proper indoor ventilation is recognized as a way to reduce the spread of COVID-19, a new study from MIT says maintaining the proper relative humidity in indoor spaces like your residence might help keep you healthy.
The "sweet spot" associated with reduced COVID-19 cases and deaths is 40%-60% indoor relative humidity, an MIT news release said. People who maintained indoor relative humidity outside those parameters had higher rates of catching COVID-19.
Most people are comfortable with 30%-50% relative humidity, researchers said. An airplane cabin has about 20% relative humidity.
Relative humidity is the amount of moisture in the air compared to the total moisture the air can hold at a given temperature before saturating and forming condensation.

The study was published in The Journal of the Royal Society Interface. Researchers examined COVID-19 data and meteorological measurements from 121 countries from January 2020 through August 2020, before vaccines became available to the public.




"When outdoor temperatures were below the typical human comfort range, they assumed indoor spaces were heated to reach that comfort range. Based on the added heating, they calculated the associated drop in indoor relative humidity," the MIT news release said.
The research teams found that when a region reported a rise in COVID-19 cases and deaths, the region's estimated indoor relative humidity was either lower than 40% or higher than 60%, the release said.
"There's potentially a protective effect of this intermediate indoor relative humidity," said Connor Verheyen, the lead author and a PhD student in medical engineering and medical physics in the Harvard-MIT Program in Health Sciences and Technology.

Widespread use of the 40%-60% indoor humidity range could reduce the need for lockdowns and other widespread restrictions, the study concluded.
"Unlike measures that depend on individual compliance (e.g. masking or hand-washing), indoor RH optimization would achieve high compliance because all occupants of a common indoor space would be exposed to similar ambient conditions," the study said. "Compared to the long timelines and high costs of vaccine production and distribution, humidity control systems could potentially be implemented more quickly and cheaply in certain indoor settings."

Sources​

MIT: "Keeping indoor humidity levels at a "sweet spot" may reduce spread of Covid-19."

The Journal of the Royal Society Interface: "Associations between indoor relative humidity and global COVID-19 outcomes."

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[missy]

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Major Life Stressors 'Strongly Predictive' of Long COVID Symptoms​

Megan Brooks

After recovery from acute infection with SARS-CoV-2, major stressful life events such as the death of a loved one or financial insecurity can have a significant impact on the development of long COVID symptoms, new research suggests.

Major life stressors in the year after hospital discharge for COVID-19 are "strongly predictive of a lot of the important outcomes that people may face after COVID," lead investigator Jennifer A. Frontera, MD, a professor in the Department of Neurology at NYU Langone Health, New York City, told Medscape Medical News.

These outcomes include depression, brain fog, fatigue, trouble sleeping, and other long COVID symptoms.


The findings were published online November 5 in the Journal of the Neurological Sciences.

Major Stressful Events Common​

Frontera and the NYU Neurology COVID-19 study team evaluated 451 adults who survived a COVID hospital stay. Of these, 383 completed a 6-month follow-up, 242 completed a 12-month follow-up, and 174 completed follow-up at both time points.

Within 1 year of discharge, 77 (17%) patients died and 51% suffered a major stressful life event.


In multivariable analyses, major life stressors — including financial insecurity, food insecurity, death of a close contact, and new disability — were strong independent predictors of disability, trouble with activities of daily living, depression, fatigue, sleep problems, and prolonged post-acute COVID symptoms. The adjusted odds ratios for these outcomes ranged from 2.5 to 20.8.

The research also confirmed the contribution of traditional risk factors for long COVID symptoms, as shown in past studies. These include older age, poor pre-COVID functional status, and more severe initial COVID-19 infection.

Long-term sequelae of COVID are increasingly recognized as major public health issues.

It has been estimated that roughly 16 million US adults aged 18 to 65 have long COVID, with the often debilitating symptoms keeping up to 4 million out of work.

Holistic Approach​

Frontera said it's important to realize that "sleep, fatigue, anxiety, depression, even cognition are so interwoven with each other that anything that impacts any one of them could have repercussions on the other."


She added that it "certainly makes sense that there is an interplay or even a bi-directional relationship between the stressors that people face and how well they can recover after COVID."


Therapies that lessen the trauma of the most stress-inducing life events need to be a central part of treatment for long COVID, with more research needed to validate the best approaches, Frontera said.


She also noted that social services or case management resources may be able to help address at least some of the stressors that individuals are under — and it is important to refer them to these resources. Referral to mental health services is also important.


"I think it's really important to take a holistic approach and try to deal with whatever the problem may be," said Frontera.


"I'm a neurologist, but as part of my evaluation, I really need to address if there are life stressors or mental health issues that may be impacting this person's function," she added.


The study had no commercial funding. The investigators have reported no relevant financial relationships.


J Neurol Sci. Published online. Full article

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[missy]

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Restricting Attendance at NFL Games Probably Lowered COVID Rates​

F. Perry Wilson, MD, MSCE
DISCLOSURES
November 21, 2022

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson of the Yale School of Medicine.
It's football season, but that's not the only grand American tradition going on right now. No, we also seem to be in the "evaluating old COVID policies" season, as papers looking at the outcomes of decisions that public health officials made in 2020 and 2021 are bursting forth like the Wolverines from Michigan Stadium.
Last week we looked at the impact of masking in public schools, and this week we're looking at, appropriately enough, attendance at NFL games. That's right. It's time to do some Monday morning quarterbacking. We're talking about thisstudy, appearing in JAMA Network Open, which looked at the 2020-2021 football season.
The key to the study is the fact that teams did different things over the course of the season in regard to how many people they let in the stadium. You had teams like the Vikings and the Chargers, who never let any fans in the stadium, and teams like the Cowboys who had more than 20,000 fans every single game.

Did it matter? Was restricting attendance a good idea? The authors decided to see if COVID rates went up in the county where the game was held in temporal proximity to game time. They looked at 7-day windows after the game (which are probably too short to see an effect of game-day transmission) as well as 14- and 21-day windows.
But hold on — what does it mean to say that COVID rates went up? This is where the study starts to feel more like a discussion on some stock technical analysis forum than it does like a standard medical paper.
The authors tabulated case rates on a daily basis based on publicly available records. They used some statistical tweaks to account for the expected differences in reporting on weekends and the occasional data dump. They then used several different outlier detection techniques to find days where more cases than expected happened.

The simplest technique used a moving average approach. Here's an example using the Buccaneers. The black line shows the 21-day moving average case rate.

• 

You can see how it climbs from September to January — that's the Alpha variant wave; how quaint — and then starts to descend. The dots reflect individual daily case rates, and when they are significantly higher than the moving average, they are coded as outliers — yellow in this case.

In other words, the operational definition of "more cases than we'd expect" is based on the assumption that case rates should rise and fall with some smoothness. I'm not entirely confident in this approach, but I'll get to that in a minute.


Assuming we believe that those yellow dots are important signals, we can ask a straightforward question: Would games with high attendance have more yellow dots following the game than games with low or no attendance?


The authors find that they do. In both 14- and 21-day windows following attended games, there were about 30%-40% higher rates of "outlier days" compared with unattended games.

"

 

[missy]

"

Data Hint COVID-19 Vax May Improve Immunotherapy Efficacy in Some​

Nancy A. Melville
November 21, 2022


While studies have generally alleviated concerns that COVID-19 vaccination could compromise the effects of immune checkpoint inhibitors, new research offers a twist: COVID-19 vaccination could improve outcomes for certain patients with cancer.
Specifically, compared with nonvaccinated patients, vaccinated patients with advanced nasopharyngeal cancer showed higher objective response rates and disease control rates after anti-PD-1 therapy and similar rates of severe immune-related adverse events.
The Sinovac COVID-19 vaccine included in the analysis is an inactivated vaccine developed in China. It has been endorsed for emergency use by the World Health Organization and approved in dozens of countries, though not in the United States.

Overall, the study suggests that "the efficacy of combination of anti-PD-1 treatment and chemotherapy was significantly improved for vaccinated nasopharyngeal cancer patients," the authors write.




First author Jian Li, MD, of the University Hospital Bonn, Germany, told Medscape Medical News that the results were indeed "a surprise."
Given the promising outcomes associated with COVID-19 vaccination in patients receiving anti-PD-1 therapy, this study may be "valuable to clinicians and other people who are dealing with nasopharyngeal cancer," Li added.
But the authors also expressed caution about the findings, even entitling the article: "Potentially improved response of COVID-19 vaccinated nasopharyngeal cancer patients to combination therapy with anti-PD-1 blockade and chemotherapy."

The analysis was published online last month in Annals of Oncology.
Experts have raised concerns about whether anti-PD-1 treatment might interfere with COVID-19 vaccination in patients with nasopharyngeal cancer, given that both COVID-19 and nasopharyngeal cancer affect the upper respiratory tract.
Li and colleagues have previously found that patients with metastatic lung, liver, or intestinal tract cancers receiving PD-1 inhibitors had no significant differences in outcomes after COVID-19 vaccination, and wanted to extend their research to patients being treated for nasopharyngeal cancer.

The authors evaluated 1537 patients with nasopharyngeal cancer who were enrolled at 23 hospitals in China from January 2021 and followed through to June 2022.


All patients — who were mostly men with a median age of 45 years — had a recurrent metastatic stage of cancer, and most were receiving concomitant anti-PD-1 therapy along with chemotherapy. About one quarter of patients (n = 373) had received the Sinovac COVID-19 vaccine and started anti-PD-1 therapy a median of 105 days after vaccination (range, 24-154 days). The remaining 75.7% of participants were not vaccinated against COVID-19.


Overall, 140 patients (9%) achieved complete remission during the study period, 503 (32.7%) had partial remission, 526 (34%) achieved stable disease, and 337 (22%) had progressive disease.


Compared with the non-vaccinated subgroup, vaccinated patients showed a significantly higher objective response rate (59.0% vs 38.8%) and disease control rate (80.2% vs 74.7%) following anti-PD-1 treatment.


Vaccinated patients were more likely to experience mild immune-related adverse events (73.6% vs 60.1%; P < 0.001), but not severe immune-related adverse events.





In a propensity score analysis of 1119 patients, the researchers matched patients according to age, gender, Karnofsky performance status, and body mass index, and observed similar results.


Compared with the non-vaccinated subgroup, vaccinated patients had a significantly higher objective response rate (59.0% vs 35.7%) and disease control rate (80.2% vs 72.5%), but similar rates of severe immune-related adverse events (4.9% vs 4.1%; P = .482).


Although the potential association between COVID-19 vaccination and increased efficacy of anti-PD-1 therapy in recurrent metastatic nasopharyngeal cancer is "interesting," the finding "needs to be validated in a larger cohort study," Li and colleagues conclude.


In addition, the mechanism underlying the findings remains unclear and would need to be elucidated in further studies. The authors proposed a few possible explanations, including that "exhausted CD8+ T cells could be reactivated in the tumor microenvironment during vaccination, facilitating immunotherapy."


Alexandre Malek, MD, who was not involved in the research, shared the authors' cautious optimism.


The findings are "promising," but "the hypothesis needs further in-depth investigation at the granular level to generalize and validate the results," said Malek, who is assistant professor of medicine in the Division of Infectious Diseases, Louisiana State University Health Shreveport.


Malek pointed to "a growing number of preclinical studies evaluating the role of vaccines as adjunct to immunotherapy to overcome cancer resistance by converting cold tumors to hot."


That research includes a study of a seasonal influenza vaccine and another of adenoviral based-vaccines.


It's also possible that vaccination against human papillomavirus (HPV) could benefit patients with nasopharyngeal cancers — many of which are associated with HPV, Malek noted.


"Novel anti-cancer therapies are underway to tackle HPV-positive nasopharyngeal cancer by using immune checkpoint inhibitors along with HPV vaccine as a way to enhance antitumor activity," Malek explained.


Given this, a key limitation of the current study is the lack of information on rates of viral-driven nasopharyngeal cancer, specifically HPV versus Epstein-Barr virus, he noted.


Still, the study "constitutes burgeoning data to unlock the role of new vaccines as adjunct to anti-cancer therapies, primarily immune checkpoint inhibitors, to promote and optimize immunogenicity and overcome tumor resistance," Malek said.


The study was funded by the Sino-German Center for Research Promotion (SGC), the DFG Cluster of Excellence ImmunoSensation², and the German Federal Ministry of Education and Research (BMBF). The authors and Malek have reported no relevant financial relationships.


Ann Oncol. Published online. Full text

"

 

[missy]

From a newsletter my former physician sends every season

"

The overwhelming message that you are going to hear in this newsletter is, “Hey, you! Yes, you. Get vaccinated!” I cannot stress enough how effective vaccines are in preventing disease and death. Yes, they might have some annoying side effects, but these side effects are laughable compared to the symptoms you could face if you contracted the vaccine-preventable disease.


I ordered 200 fewer flu shots this year than last, because I figured some people would get the flu shot at the pharmacy along with their Covid-19 booster. But a number of patients have reported that they have not yet received their bivalent booster or flu shots. I have hundreds of flu shots lying useless in my fridge, despite ordering 20 fewer boxes than last year. These are scientifically proven, life-saving medicines that are free or low cost and widely available. Come in and get one! If you do not see a time that works for you on my office-visit schedule, email me and we can get it sorted.


I know that with all of the boosting some of you have vaccine fatigue, but I have to say it again: Vaccines work.They have saved countless lives. They are the way forward to prevent another surge. I turned 50 this year, so in the past few months I’ve had: Covid booster #4, Shingrix #1, Shingrix #2, flu, and Covid bivalent booster. Nobody loves getting shots, including me, but I love knowing that I have done all I can to keep myself and my community safe.


Enjoy this lovely autumn, secure in the knowledge that you have protected yourself and your community to the best of your ability.






Speaking of vaccines: Universal Hep B Vaccination


The CDC recently recommended universal hepatitis B vaccines for everyone aged 19 to 59. Mandatory hepatitis B vaccination of infants and children started in 1991, so everyone under 19 should have already received the hepatitis B vaccine.


Before now, hep B vaccination was recommended only for those with a high risk of hepatitis B. Hep B is spread in the same way as HIV: unprotected sex with an infected person, sharing needles with an infected person and blood transfusion. The reason the CDC is now recommending universal hep B vaccination is that rates of hep B have increased by 45% in adults.


There is a blood test that can determine if you are immune to hep B. If you are immune, nothing more needs to happen. If you are not immune then you should return for the series of hep B vaccines.


Fall Triple Threat


Influenza

Whereas flu typically starts to trickle in around November and reaches a peak December through February, this year has started with a bang. Flu started circulating in October and has increased by about 125% every week since.


The past two flu seasons have been mild due to distancing and masking. Looking at pediatric flu deaths as a marker for season severity, the year before Covid (2019) there were about 200 pediatric flu deaths. In 2020, with rigorous distancing and masking, there was 1 (!) pediatric flu death. In 2021, the number rose to 33. We have already seen 5 pediatric flu deaths this flu season, and the season has barely begun. We also look to Australia to predict what the coming flu season will look like in the States, because our summer is their winter. Australia had its worst flu season in 5 years, with cases hitting three times higher than average.


If you have not yet received your flu shot, come in immediately to get covered!!!


Even if you personally are at low risk of death from flu, getting the shot can prevent the death of at-risk people you might infect before you realize that you are contagious.


RSV

Infants and children are especially hard hit during this flu season because of an early and marked increase in RSV (respiratory syncytial virus). Pediatric wards in hospitals all over the country are at capacity, with cases increasing week to week.


There is no vaccine for RSV. The best protection is to get yourself and your child vaccinated for the flu and for Covid-19 to reduce the chance of having one of those illnesses on top of the RSV, as this combination is particularly dangerous. Both flu and Covid vaccines are approved for children 6 months and older. I have seen firsthand the deep regret and guilt that parents have when their child is suffering from a vaccine-preventable disease. Don’t let that be you. Vaccines are safe and effective.


Covid-19

Covid-19 is currently co-circulating with the flu and RSV. In NYC, the case rate is 11% positive. Deaths and hospitalizations started trending upward in mid-October.

Remember back before the vaccine, when schools would close if the case rate was more than 3% positive? They did it because the death rate from Covid was so high. Why is the death/hospitalization rate so low that we can now tolerate an 11% positive and not even require masking in schools? Vaccines!


Vaccines work. Vaccines are life-saving. Follow the science and get your bivalent booster.


If you have not gotten your Covid Bivalent Booster (Omicron booster), schedule an appointment right away!


I was able to get 50 single dose vials of the Pfizer Bivalent Covid booster so you can book an appointment in the vaccine schedule to get one here!


A study was just released that showed a significant increase in risk of severe disease and complications with repeated Covid infections.

“People in the study with repeat infections were more than three times more likely to develop lung problems, three times more likely to suffer heart conditions and 60% more likely to experience neurological disorders than patients who had been infected only once. The higher risks were most pronounced in the first month after reinfection but were still evident six months later, researchers found.”


https://www.reuters.com/business/he...-than-first-infection-study-finds-2022-11-10/


Paxlovid

Covid antivirals are still recommended only for people at an increased risk of severe disease and death. People with average risk should not get too excited over the news that Paxlovid can decrease long Covid by 26%, because the study was done only with patients at a high risk of severe disease or death. The study was done at a VA hospital and most participants were older white men.


The New York Times says:

The study, which was published online without undergoing peer review, does not indicate whether antivirals might be beneficial for other patients, like younger people or those without high-risk medical conditions. And it does not give any inkling whether Paxlovid might be a treatment for long Covid itself, a question being investigated by other researchers.

The full article can be found here:

https://www.nytimes.com/2022/11/07/health/paxlovid-long-covid.html


What to do when you are sick

At the first sign of a respiratory illness, think about protecting others. Stay home and isolate until it is proven that your illness is not Covid or flu. Do a rapid Covid test at home (a negative test on Day 1 of illness does not totally rule out Covid). Do not leave home if you have a fever over 100.4° F. If you do not have a fever and you test negative for Covid, you can go about your day but you should wear a well-fitted mask and practice good respiratory and hand hygiene.



Prevention

In addition to vaccination, masking and hand hygiene are great protectors. Hand washing has saved more lives than any other medical innovation. I strongly recommend wearing a mask indoors in public spaces for the duration of cold/Covid/RSV/flu season.


Remember that only KN/N94 or KN/N95 masks protect you from other people. All other masks only protect other people from you. While Covid is spread from person to person and does not live well on surfaces, flu and cold viruses are frequently passed from surfaces. I therefore recommend hand washing or using hand sanitizer upon arriving at your destination when you travel or commute. I recommend washing hands or using hand sanitizer before touching your eyes, nose, or mouth while out and about. And, as always, wash hands or sanitize your hands before eating.


Holiday Safety

Now is a great time to start talking with friends and family about respiratory virus safety measures for holiday gatherings.


The bare minimum for holiday safety is to make sure that everyone does a rapid test for Covid on the day of the holiday get-together. Anyone who has any of the following symptoms should stay home: sore throat, runny nose, cough, fever, body aches, nausea, diarrhea.


The Bad News about Alcohol


The Covid pandemic sparked an increase in alcohol consumption for a lot of people, leading to a 25% increase in alcohol-related deaths from 2019 to 2020; increased drinking by women was the main driver in increased deaths. Studies done before the pandemic already noted a marked increase in alcohol-related disease among women due to increases in alcohol consumption, perhaps associated with “mommy wine culture.”

https://www.huffpost.com/entry/mom-stress-without-wine_l_621cf83be4b03d0c803cc340


A new study from Mass General Hospital shows that:

• A one-year increase in alcohol consumption in the U.S. during the Covid pandemic is estimated to cause 8,000 additional deaths from alcohol-related liver disease, 18,700 cases of liver failure, and 1,000 cases of liver cancer by 2040.
• A sustained increase in alcohol consumption for more than one year could result in 19–35% additional mortality.

For those of you who have been drinking more since the pandemic started, I would definitely recommend that you reduce your alcohol consumption to no more than one drink in a given day. A drink is defined as 1.5 oz of spirits, 5 oz of wine, or 12 oz of beer. You could also consider not drinking alcohol at all. I know many of you have still not gotten over the horrible news that there is no safe level of bacon. Well, hold on to your hats!

https://news.harvard.edu/gazette/st...ted-drinking-linked-to-rise-in-liver-disease/

https://www.today.com/health/womens-health/alcohol-women-drinking-risks-rcna24808

Back in 2018, a Global Burden of Disease study was published in the Lancet that stated there was no safe level of alcohol for humans to consume.

https://www.npr.org/2018/08/24/6416...l-is-good-for-your-health-global-study-claims

In 2019, researchers in Japan published a study that showed increased cancer rates even among light to moderate drinkers.

https://www.hsph.harvard.edu/news/hsph-in-the-news/japan-moderate-alcohol-cancer-risk/


In 2021, a study from Oxford University showed that the consumption of alcohol reduces brain volume. Reduction of brain volume can lead to cognitive deficits.

https://www.cnn.com/2021/05/19/health/alcohol-brain-health-intl-scli-wellness


Bottom line: There is no totally safe level of alcohol, so it is best to have none.

If you are going to drink, it is best to limit yourself to one drink in a given day. If you have gotten into a habit of drinking alcohol to wind down after a long day, consider an alternative. Probably a lot of what you are enjoying with this habit is just the sitting down and relaxing part. Try doing it with a non-alcoholic beverage. Alternatively, start doing a mindfulness practice instead. Multiple studies show that even 5-10 minutes of a mindfulness practice (yoga, meditation, guided imagery, journaling, deep breathing) can significantly reduce stress and anxiety.


Another hidden consequence of the pandemic is social isolation. Consider reaching out not only to family members, but also anyone who you think might need your support or just some company. Reach out if you need extra support, too. The holidays can be fun but they can also be quite stressful. Ask friends and family about their needs and update them on your needs. Be kind but firm with boundaries around time and around important Covid/flu/RSV precautions.



"

 

[missy]

"

How infectious disease experts are responding to Covid nearly three years in​

• 

By Helen Branswell Nov. 21, 2022

JOHN MOORE/GETTY
The world is fast approaching the third anniversary of those days when we got our first inkling that a new disease was spreading in China. In the months that followed, normal life was suspended, then upended. At this point, everyone is well and truly sick of Covid-19 and the accommodations we have had to make to co-exist with it.

So sick of it, in fact, that many people appear to have given up trying to avoid the SARS-CoV-2 virus. Restaurants are packed, airports are hopping. Once-ubiquitous masks are now an increasingly rare sight.

With Thanksgiving only days away, STAT asked infectious diseases experts how they’re handling the risk of catching Covid at this point. We’ve done this twice before, you may recall, when the Delta wave was surging in August 2021, and a few months later, just before Thanksgiving.



This time we wondered if people who work in the infectious diseases sphere are still taking steps to try to avoid catching the virus, and if so, which ones. We also wondered whether — maybe even hoped — they are feeling less stressed about Covid and are starting to lower their guard.

The short answer: Some appear to be, a little. But most are still using multiple measures to try to avoid Covid.





We surveyed epidemiologists, virologists, immunologists, and related experts, asking a series of “yes” or “no” questions; 34 replied. It quickly became apparent “not applicable” had to be an option for some questions; some of our respondents created a “maybe” category for a few.

One person who is battle-scarred from fighting the Covid wars begged off. “Between the militant zero-Covid crowd on one side and the ‘it’s just a cold’ crowd on the other, there is a lot of vitriol waiting to be fired,” this individual explained. Another answered, but asked not to be named, for the same reason.

Let’s dive into their answers to our questions.

Despite the fact that most of the people we surveyed are still taking precautions, those with young kids or grandkids reported the children are pretty much back to living pre-Covid-style lives. That’s both a terrific development for the children themselves and a welcome sign of how far we’ve come.

Twenty of 21 people who answered this question reported their kids or grandkids are taking part in after-school activities, having playdates, and the like. Esther Choo, an associate professor of emergency medicine at Oregon Health and Science University, noted her kids are still wearing masks in school and in other indoor settings. Grace Lee, professor of pediatrics at Stanford University School of Medicine, also said her kids mask up for group activities indoors.

Craig Spencer, an emergency room physician and associate professor at Brown University’s School of Public Health, acknowledged putting more limitations on the interactions of his two young children, saying “given the panoply of viruses circulating (flu, RSV and Covid) we are still limiting indoor playdates for them.” His 4-year-old daughter, for example, will have an early birthday party, before the weather gets too cold to hold it outside.

We found there’s a lot more willingness to eat in restaurants or attend indoor concerts or sports events than last year. Uché Blackstock, an emergency physician and CEO of the consulting firm Advancing Health Equity, has dined indoors in restaurants twice, but “it wasn’t crowded.” Megan Ranney, deputy dean of Brown’s School of Public Health, saw a Harry Styles concert in the summer, “albeit with a mask.”



Katelyn Jetelina, author of the popular Substack column “Your Local Epidemiologist,” said she’d go to a concert without a mask, as long she didn’t have an upcoming visit with grandparents or something critical at work that she couldn’t miss due to illness. “I care about transmission. However, I also care about enjoying a beer and shouting my favorite songs and, quite frankly, masks are just not welcome culturally at country concerts — so there is some social pressure at work as well,” she admitted.

When we asked about restaurant dining in August 2021, two-thirds of the respondents said they would not eat indoors; this time, nearly three-quarters said they would. Last Thanksgiving, 44% of respondents said they would not attend a large indoor event, even if masked. That figure went down to 32% this time. On concerts or sporting events, Ziyad Al-Aly is a holdout. “Noooooooooo,” replied the chief of research at the VA St. Louis Health Care System and a clinical epidemiologist at Washington University in St. Louis.

Related: The scientist behind Pfizer’s Covid vaccine says a flu pandemic is only a matter of time​

Marion Pepper, chair of the department of immunology at the University of Washington, is the only one of the respondents who doesn’t wear a mask while flying — though she dons one during take-off and landing. William Hanage, an infectious diseases epidemiologist at Harvard’s T.H. Chan School of Public Health, doesn’t mind taking his mask off to eat while in flight “because colleagues who know tell me that the ventilation mid-flight should be very good.” Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, was specific. “Not just a mask … an N-95,” he said.

The majority of respondents still wear masks while they are shopping; only four of the 33 said they don’t. Most of the rest have a hard rule about masking in stores, both for their own protection and the protection of staff and other shoppers. For a few, the rule isn’t set in concrete. “I sometimes pop into the store to pick up a few things without a mask, but I wear a mask if I’m expecting it to be busy or if I will be there a while,” said epidemiologist Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security.

All our respondents have either had a bivalent booster or are waiting to get one. Some put off getting the shot because they’d recently had Covid. Of the 10 who haven’t yet had a bivalent booster, nine planned to get one before Thanksgiving. Kristian Andersen, a professor of immunology and microbiology at the Scripps Research Institute, plans to wait a little longer “since I’m only 4.5 months out from my previous booster.”

All but Pepper — who had Covid earlier this year — report that they are still taking additional measures to avoid catching the virus. Many, though, stressed they take the measures as much to protect others as to protect themselves. “I’d say I’m more focused on reducing my risk of spreading respiratory illness than reducing my risk of contracting it,” said Natalie Dean, a professor of biostatistics at Emory University.



Jeanne Marrazzo, director of the division of infectious diseases at the University of Alabama in Birmingham, avoids shaking hands whenever possible. Sarah Cobey, associate professor of viral ecology and evolution at the University of Chicago, carries a device that monitors carbon dioxide levels, as does Shweta Bansal, a Georgetown University researcher who studies how social behavior affects infectious disease transmission. Vineet Menachery has a device that alerts his phone if the CO2 levels around him rise above a set point, a sign ventilation isn’t adequate to lower the risk of Covid transmission. If that happens, the coronavirus researcher at the University of Texas Medical Branch in Galveston puts on a mask.

For most of our experts, though, attempting to avoid Covid doesn’t mean forgoing a traditional Thanksgiving this year. Most report they’re hosting or attending a large, multi-generational Thanksgiving feast. Last year, the experts we surveyed were virtually split on the idea of a large family gathering for the holiday.

Twenty-seven of our experts will be celebrating Thanksgiving with a crowd this year and most of the ones who aren’t said their decision to forgo a big gathering wasn’t Covid-related. Two are expats without extended family in the United States, and two will be traveling out of the country over Thanksgiving. Only Saskia Popescu, an assistant professor in the biodefense program at George Mason University’s Schar School of Policy and Government, scaled back her plans because of Covid concerns.

“My older and more vulnerable family [members] aren’t interested in the booster (sigh) and we all felt it best to avoid travel and larger events, so sticking with just immediate family and a couple of friends who are all fully vaccinated and are frequently tested for work,” Popescu wrote in an email.

There was an even split on the issue of whether unvaccinated relatives would be allowed to attend the family gatherings, with eight respondents saying they would and eight saying they would not. “Yes, with a negative Covid test,” said Akiko Iwasaki, an immunologist at Yale University. Syra Madad, senior director for NYC Health + Hospitals’ special pathogens program, said being unvaccinated is not a dealbreaker for entry to her gathering. “But I always share the number of people who are coming and the overall venue, so guests can decide if they have young, unvaccinated children or elderly individuals to make their own personal decision.”

Eleven respondents, the largest group on this question, said the vaccination status of their Thanksgiving guests isn’t an issue. “I don’t have any unvaccinated family members!” said Ellen Foxman, an immunologist at Yale. “All of my close and distant family members are vaccinated and boosted,” said Andrew Pavia, chief of pediatric infectious diseases at the University of Utah.

Of those hosting Thanksgiving feasts, a clear majority will use rapid Covid tests to lower the risk someone might leave with more than just a Tupperware container filled with leftovers. Eighteen said they would likely be using rapid tests. “Leaning in that direction to protect a brand-new baby and a 99-year-old great-grandmother,” said Jesse Goodman, a professor of internal medicine at Georgetown University. Eight said they won’t require it, though “… there will be lots of voluntary testing,” said Saad Omer, director of Yale’s Institute for Global Health. Robert Wachter, chair of the University of California, San Francisco’s department of medicine, still isn’t sure. “Depends on case rates,” he said.

Correction: A previous version of this article incorrectly stated that infectious disease experts were polled. They were questioned as part of an informal survey.

"